Management Of Parenteral Nutrition Research Articles

Fat malabsorption in short bowel syndrome: A review of pathophysiology and management.

Fat malabsorption is central to the pathophysiology of short bowel syndrome (SBS). It occurs in patients with insufficient intestinal surface area and/or function to maintain metabolic and growth demands. Rapid intestinal transit and impaired bile acid recycling further contribute to fat malabsorption. A significant portion of patients require parenteral nutrition (PN) for their survival but may develop sepsis and liver dysfunction as a result. Despite advancements in the treatment of SBS, fat malabsorption remains a chronic issue for this vulnerable patient population. Peer-reviewed literature was assessed on the topic of fat malabsorption in SBS. Current management of patients with SBS involves dietary considerations, PN management, antidiarrheals, glucagon-like peptide 2 agonists, and multidisciplinary teams. Clinical trials have focused on improving intestinal fat absorption by facilitating fat digestion with pancreatic enzymes. Targeting fat malabsorption in SBS is a potential pathway to improving lifestyle and reducing morbidity and mortality in this rare disease.

Information systems in clinical pharmacy applied to parenteral nutrition management and traceability: a systematic review

ObjectiveTo review the scientific literature on clinical pharmacy information systems applied to parenteral nutrition (PN) management and traceability. MethodA systematic review of the documents retrieved from the MEDLINE (PubMed), Web of Science, Scopus, Cochrane Library, International Pharmaceutical Abstracts (IPA) and Google Scholar databases up to May, 2016. The terms used, as descriptors and free text, were: „Parenteral Nutrition“ and „Drug Information Services“. The quality of the articles was assessed using the STROBE Questionnaire. The search was completed through consultation with experts and the bibliographic review of the articles selected. ResultsFrom the 153 references retrieved in our search, after applying inclusion and exclusion criteria, only 6 articles were selected for review. In three of them, flowcharts or some kind of graphical notation were designed in order to develop standard management systems, while three were based on computer programs. In two of the articles selected, a comprehensive management system had been designed for PN control and traceability. ConclusionsPN must be integrated within a standardized system, to ensure its quality and reduce the risks associated with this therapy. The development of technologies applied to PN would enable to set up management systems that are more complete and easier to apply in a real setting. Therefore, we think it will be necessary to generate new specific articles and developments associated with PN management and traceability, In order to allow their constant monitoring and assessment.

Dilemmas in the delivery of intravenous lipid emulsions and approach to hypertriglyceridemia in very preterm and low birth weight infants.

Intravenous lipid emulsions (ILEs) are an essential component of parenteral nutrition for very preterm and very low birth weight infants (VLBWs). This article offers a perspective on advancements and controversies on ILE use in this population. ILEs prescribed after birth at a dose of 1.5-2 g/kg/day and advanced to 3 g/kg/day enhance growth. Growth appears to be similar for infants who receive an ILE composed of 100% soybean oil or a multi-oil ILE with 15% fish oil. 100% fish oil is the preferred ILE for the management of parenteral nutrition associated cholestasis and intestinal failure associated liver disease. Research is warranted to help determine how we can optimize ILEs to improve neurodevelopment and prematurity complications. Last, we lack a universal definition of hypertriglyceridemia (HTG) and consensus on triglyceride surveillance and HTG management. Investigation is required to determine the health impact of specific triglyceride ranges in very preterm infants and VLBWs.

Evaluation of an electronic health record documentation tool use to improve pharmacist intervention tracking in the intensive care unit

AbstractPurposePharmacists are integral members of the healthcare team, but interventions are not always captured due to documentation limitations. This study evaluated the impact of implementing a tracking tool to address gaps in capturing pharmacist interventions.MethodsA prospective, observational study was conducted to assess pharmacist interventions between July and November 2020. Twelve critical care pharmacists captured interventions on 10 weekdays using a tracking tool (iVent—Epic®) embedded in the electronic medical record (EMR) to capture high frequency interventions not standardly captured via existing standard note documentation (e.g., renal/hepatic dose adjustment, parenteral nutrition management). Value added of the interventions is proposed. Patients' baseline demographics, interventions, Sequential Organ Failure Assessment (SOFA) score, and intensive care unit (ICU) length of stay (LOS) were collected. The primary outcome was to determine the added benefit of using a tracking tool within the EMR to capture pharmacist interventions compared to progress note documentation.ResultsTwo thousand seven hundred and eighty‐three interventions were documented on 514 unique patients over 120 pharmacist shifts. Of these, 2363 (84.9%) interventions were captured through iVent tracking. The median SOFA score on day of intervention was 4 [interquartile range (IQR) 2–7] and ICU LOS was 3.5 days [IQR 1.5–9]. The median number of interventions per patient per day was 2 [IQR 1–3]. A significant difference was observed among days of the week and the number of iVents documented (χ2 = 13.172, p = 0.01, df = 4). The post hoc pairwise comparison revealed more documented iVents on Tuesday than Friday.ConclusionThis study reveals that an iVent tracking tool increased total capture of pharmacist interventions by 563%. These interventions can be associated with value‐based programs and further work is needed in highlighting the pharmacist's role in these new payment models. This study confirms that the current standard practice at this institution of solely entering pharmacist progress notes into the patient chart misses a majority of pharmacist interventions.

Short Bowel Syndrome in neonates and early infancy

Short bowel syndrome (SBS) is the commonest cause of intestinal failure in neonates. SBS results from widespread damage to the small intestine, leading to loss of functional capacity of this organ. This is generally secondary to conditions like necrotizing enterocolitis, gastroschisis, intestinal atresia, and midgut volvulus. The small bowel usually adapts to this damage in due course of time. The clinician's role usually entails the management of parenteral nutrition and the fluid and electrolyte balance to tide over this phase. The management should be initiated as soon as the diagnosis is suspected, especially post-surgical resection of the bowel. This should comprise enteral nutrition, with proactive monitoring and supplementation of electrolytes and micronutrients. Intestinal lengthening procedures like the Serial transverse enteroplasty (STEP), and Longitudinal intestinal lengthening and tailoring (LILT) may be considered in infants, where medical therapy fails to correct the pathology. The intricate nature of the condition warrants a multi-disciplinary approach, involving clinicians, intensivists, and surgeons, which ensures the best neonatal outcomes, in terms of the survival rates in these babies.

Nutrition support teams: Institution, evolution, and innovation.

The historical institution, evolution, and innovations of nutrition support teams (NSTs) over the past six decades are presented. Focused aspects of the transition to transdisciplinary and patient-centered care, NST membership, leadership, and the future of NSTs are further discussed. NSTs were instituted to address the need for the safe implementation and management of parenteral nutrition, developed in the late 1960s, which requires the expertise of individuals working collaboratively in a multidisciplinary fashion. In 1976, the American Society for Parenteral and Enteral Nutrition (ASPEN) was established using the multidisciplinary model. In 1983, the United States established the inpatient prospective payment system with associated diagnosis-related groupings, which altered the provision of nutrition support in hospitals with funded NSTs. The number of funded NSTs has waxed and waned since; yet hospitals and healthcare have adapted, as additional education and experience grew, primarily through ASPEN's efforts. Nutrition support was not administered in some instances by the "core of four" (physician, nurse, dietitian, pharmacist). The functions may be carried out by a member of the core of four not associated with the parent discipline, in accordance with licensure/privileging. This cross-functioning has evolved into the adaptation of the concept of transdisciplinarity, emphasizing function over form, supported and enhanced by "top-of-license" practice. In some institutions, nutrition support has been incorporated into other healthcare teams. Future innovations will assist NSTs in providing the right nutrition support for the right patient in the right way at the right time, recognizing that nutrition care is a human right.

One-chamber and two-chamber parenteral nutrition admixtures for pediatric and adult patients: An evaluation of physico-chemical stability at room and cold temperature

ObjectivesThe aim of this study was to evaluate the physico-chemical stability of compounded total parenteral nutrition admixtures through peroxidation assay and ultraviolet-visible spectroscopy, high-performance liquid chromatography analysis, nuclear magnetic resonance spectrometry, pH meter, and dynamic light scattering. MethodsThe present study considered parenteral nutrition (PN) admixtures for pediatric and adult patients. The admixtures were characterized by a high content of vitamins and trace elements. They were prepared in one- or two-chamber bags in the hospital pharmacy using an automatic compounding system in a sterile room with laminar airflow at different temperature conditions and light exposure. The experiment setup comprised fat emulsions, lipid-free PN solutions, and single-chamber bags before and after adding vitamins and trace elements. The stability at room temperature (+25°C) and cold temperature (+2–8°C) was assessed by various means. ResultsTwo-compartment admixtures, single-chamber bags, and all-in-one PN supplemented with vitamins and trace elements are stable up until 35, 9, and 7 d, respectively, when protected from light and stored at +2 to 8°C. Also, the supplemented single-chamber PN was found to be stable up to 48 h when stored at +25°C with light exposure. ConclusionsThe results obtained will help improve PN management at the compounding center and in hospital wards, because they allow for the extension of the validity time frame provided so far by the different formulations and, therefore, therapy scheduling over several days.

Can we agree on pediatric parenteral nutrition? a quality appraisal of the available guidelines

Rationale: Pediatric patients with a particular condition or underline complications, often require specialized nutritional support, sometimes in the form of intravenous administration. Hence, the use of high quality, evidence-based clinical practice guidelines (CPGs) with the application of conscientious criteria is required. The purpose of this study was to critically appraise published CPGs on management of parenteral nutrition (PN) in pediatric patients.

Clinical Outcomes of Pediatric Chronic Intestinal Pseudo-Obstruction.

Chronic intestinal pseudo-obstruction (CIPO) is an extremely rare condition with symptoms of recurrent intestinal obstruction without any lesions. The outcomes of pediatric CIPO and predictors for the outcomes have not yet been well established. We analyzed the clinical outcomes and associated factors for the outcomes of pediatric CIPO. We retrospectively reviewed 66 primary CIPO patients diagnosed between January 1985 and December 2017. We evaluated parenteral nutrition (PN) factors such as PN duration, PN use over 6 months, home PN, and mortality as outcomes. We selected onset age, presence of urologic symptoms, pathologic type, and involvement extent as predictors. The early-onset CIPO was found in 63.6%, and 21.2% of the patients presenting with urologic symptoms. Of the 66 patients, 47 and 11 had neuropathy and myopathy, respectively. The generalized involvement type accounted for 83.3% of the cases. At the last follow-up, 24.2% of the patients required home PN management. The mean duration of PN was 11.8 ± 21.0 months. The overall mortality rate of primary CIPO was 18.2%. PN factors were predicted by the urologic symptoms and extent of involvement. However, mortality was predicted by pathologic type. The onset age was not significantly associated with the outcomes. CIPO with urologic symptoms and generalized CIPO had poor PN outcomes. Myopathy is suggested as a predictor of mortality in children with primary CIPO.

Parenteral Nutrition Process Management for Newborn and Preterm Infants - A Preliminary Risk Analysis.

BackgroundThere are variable practices in the management of the parenteral nutrition (PN) process in hospitals having a neonatal intensive care unit (NICU). In our hospital, PN is prepared partially on the neonatal ward by nurses but also at the central pharmacy by trained pharmacy technicians. A previous study showed a concentration non-conformity of 34% of on-ward PN preparations potentially resulting in under- or overfeeding of the patients.ObjectiveThe objectives were to perform preliminary risk analyses (PRA) in preparation for our hospital’s transition to universal central pharmacy PN compounding.MethodsA working group including pharmacists, neonatologists, nurses, and pharmacy technicians performed two PRA. The risks of 9 management steps of the PN process were identified, evaluated, and quoted. A comparison of the number of risks and their criticality index (CI) was conducted.ResultsA total of 36 and 39 risks were identified for PN preparation in the NICU and the pharmacy, respectively. For the NICU, ten risks (28%) had an “acceptable” CI, 15 risks (42%) were “under control” and eleven (31%) were defined as “non-acceptable”. For the pharmacy, 14 risks (36%) had an “acceptable” CI, 19 risks (49%) were “under control” and six (15%) were defined as “non-acceptable”. Risks directly related to the preparation process, including the steps preparation hood, PN preparation and analytical quality control, represented a cumulated CI of 145 for eleven NICU-risks vs 108 for twelve pharmacy risks (−26%). The implementation of immediate improvement measures, eg, an electronic prescription form, reduces the total CI by 5.7% and 2.2% for the NICU and the pharmacy, respectively.ConclusionThis PRA highlighted the safety differences between PN preparation in the NICU vs the pharmacy at our institution, and facilitated our moving forward with a process change that should improve the care of our neonatal patients. Nevertheless, long-term improvement measures have to be implemented to further reduce risks related to the PN management process.

Total Parenteral Nutrition Management Based on Intravenous Drug Compounding Service

Total parenteral nutrition treatment is complex and has serious and detrimental complications, including catheter-related blood stream infections, fluid and electrolyte imbalance, hyperglycemia and hypercalcemia. This research examines how Intravenous Drug Compounding Service (IDCS) figures in total parenteral nutrition prescriptions reviewed by pharmacists, strengthens hospital clinical care and improves patients’ health. For this study, a total of 56164 nutritional prescriptions or medical orders from a hospital in Guangdong from 2016 to 2020 were randomly selected. According to whether IDCS was administered, the patients were divided into two experimental groups: the intervention group and the control group. The types and numbers of irrational prescriptions in the two groups were analyzed and compared, and further analysis of the role of IDCS in improving the level of nutritional prescriptions was performed. The results showed that the rate of irrational prescriptions in the intervention group from 2016 to 2020 was significantly lower than that in the control group, and the difference was statistically significant (P<0.01). The total irrational prescription rate in the intervention group was 32.53‱ on average, which was significantly lower than the 156‱ in the control group. The difference was statistically significant (P<0.01). After the administration of IDCS, the incidence rates of both total prescription errors and formulation errors were significantly lower than the incidence rate of irrational prescriptions without pharmacists’ intervention. The study confirms the importance and necessity of IDCS, so that patients can receive more efficient nutrition and health management services.

Clinical Impact of Prescribed Doses of Nutrients for Patients Exclusively Receiving Parenteral Nutrition in Japanese Hospitals: A Retrospective Cohort Study.

BackgroundIn patients receiving parenteral nutrition (PN), the association between nutrition achievement in accordance with nutrition guidelines and outcomes remains unclear. Our purpose was to assess the association between nutrition achievement and clinical outcomes, including in‐hospital mortality, activity of daily living (ADL), and readmission.MethodsIn this retrospective cohort study, data were extracted from an inpatient medical‐claims database at 380 acute care hospitals. This study included patients who underwent central venous catheter insertion between January 2009 and December 2018. Patients were classified into 3 groups: (1) target‐not‐achieved; (2) target‐partially‐achieved; and (3) target‐achieved. The target doses of energy, amino acids, and lipid were defined as ≥20 kcal/kg/day, ≥1.0 g/kg/day, and ≥2.5 g/day, respectively. To examine the effect of nutrition achievement on outcomes, a multivariable logistic regression analysis was performed.ResultsA total of 54,687 patients were included; of these, 21,383 patients were in the target‐not‐achieved group, 29,610 patients were in the target‐partially‐achieved group, and 3694 patients were in the target‐achieved group. The adjusted odds ratio (OR) (95% CI) for in‐hospital mortality was 0.69 (0.66–0.72) in the target‐partially‐achieved group and 0.47 (0.43–0.52) in the target‐achieved group with reference to the target‐not‐achieved group. The adjusted ORs for deteriorated ADL was 0.93 (0.85–1.01) in the target‐partially‐achieved group and 0.77 (0.65–0.92) in the target‐achieved group with reference to the target‐not‐achieved group. Readmission was not associated with nutrition achievement.ConclusionIn‐hospital mortality was lower and deteriorated ADL was suppressed in patients whose PN management was in accordance with the nutrition guidelines.

Utilization of a standardized discharge checklist to improve the transition of care for patients receiving parenteral nutrition.

Guidelines recommend using discharge checklists to discharge patients receiving parenteral nutrition (PN). Transition-of-care (TOC) tools have not been extensively studied in the PN population. The purpose of this study is to evaluate the impact of a standardized PN discharge checklist on TOC for PN patients. This is an Institutional Review Board-approved, retrospective quasi-experimental study of patients discharged receiving PN between January 1, 2014, and May 31, 2018. The primary end point was the completion of a PN discharge bundle (identification of a responsible provider to monitor PN after discharge, meeting daily caloric requirement of 20-35 kcal/kg/d, cycling PN prior to discharge). Secondary end points included documentation of PN discharge checklist components, hospital length of stay, frequency of 30-day hospital encounters, cause of hospital encounters, and time to readmission. Fifty encounters were included in the pregroup and postgroup each (n= 100). There was a significant increase in completion of the TOC bundle in the postgroup (54% vs 76%, P = .035), driven by identification of a responsible provider for outpatient PN management (54% vs 82%, P = .005). Other PN discharge checklist components impacted included the following: case manager had the PN prescription for home infusion (50% vs 80%, P = .003), assessment for home glucometer (40% vs 90%, P < .001), and PN plan-of-care note documentation at discharge (18% vs 82%, P < .001). A standardized PN discharge checklist improved completion of discharge bundle.

Progress Report on Cases of Peripherally Inserted Central Catheter (PICC) Management in Our Hospital, Including Elderly Patients

In our hospital, the number of cases in which peripherally inserted central catheters (PICCs) are used has increased; these patients include elderly people who cannot take medications orally, patients with low levels of awareness, and patients with dysphagia. We report the situation at this time mainly with regard to the number of days on which PICCs were used. Fifteen elderly patients (male, n=7; female, n=8; average age, 89.3±5.3 years) underwent PICC insertion at our hospital from August 2016 to October 2018. Among these patients, 6 had cerebrovascular disorders, 5 had aspiration pneumonia, 2 had Parkinson's syndrome, 1 had consciousness disorder resulting from asphyxia caused by foreign body aspiration, and 1 had interstitial pneumonia. Seven patients received home management. In each patient, we measured the length of time that the PICC was in place. The average duration for which a PICC was in place was 92.9±25.4 days (in cases of home care management, 159.5±48.3 days). The longest duration was 342 days, in a patient with aspiration pneumonia. The endpoints were death and discharge from hospital. Complications/accidents occurred as a result of catheter infection in 2 cases (both patients recovered after catheter removal) and as a result of self-extraction in 1 case. These results suggest that PICC is useful and does not cause serious adverse effects, even in elderly patients who require central parenteral nutrition management.

Alterations in parenteral nutrition management for the treatment of parenteral nutrition-associated cholestasis in term and preterm infants

Alterations in parenteral nutrition management for the treatment of parenteral nutrition-associated cholestasis in term and preterm infants

Parenteral nutrition in adults during acute illness: a clinical perspective for clinicians.

Parenteral nutrition (PN) is the administration of a nutritional formula by means other than the gastrointestinal (GI) tract. The formula may include carbohydrates, amino acids, lipids, electrolytes and/or micronutrients. The primary indications for PN are intestinal failure (IF) due to an underlying disease or treatment, or if the GI tract is not accessible. The goals of PN should be to ensure adequate nutrition provision to meet patient needs while minimising the risk of complications. PN should be commenced in <48 h in patients who are malnourished or otherwise within 7 days if oral or enteral nutrition is not possible or insufficient. There has been evolution in PN techniques and technology, and the risks associated with PN administration have been reduced. Monitoring clinical, laboratory and metabolic parameters in acute IF is essential to provision of safe nutritional support. When provided to appropriate patients with IF in a timely and considered manner, PN has been shown to be safe, improve nutritional parameters and reduce complications associated with malnutrition. This review aims to provide clinicians a practical guide for the management of PN in adult patients within the acute setting.

MON-PO496: Hepatobiliary Complications of Total Parenteral Nutrition Management with Taurine Enriched Aminoacid Solutions

MON-PO496: Hepatobiliary Complications of Total Parenteral Nutrition Management with Taurine Enriched Aminoacid Solutions

The impact of a nutrition support team over a 8 year period on the management of parenteral nutrition in type 1 intestinal failure

Rationale: Every hospital should have a nutrition support team (NST) to manage patients on artificial nutrition support. The demand for the input has increased over 8 years because of tertiary services for surgery, gastroenterology and the introduction of a regional trauma centre. In 2009, the NST was introduced in our hospital primarily to address catheter-related blood stream infection (CRBSI) rates in patients with type 1 intestinal failure (IF).

Systematic Review of Hypersensitivity to Parenteral Nutrition.

Hypersensitivity to the components of parenteral nutrition (PN) is a rare but important complication of PN. We performed a systematic review of hypersensitivity to PN to enable us to build an approach to the individual patient who presents with PN hypersensitivity. A systematic literature search was performed in Ovid Medline, CINAHL, Scopus, and Web of Science using terms for "hypersensitivity" AND "parenteral nutrition" and relevant synonyms. A total of 28 articles were analyzed, and 33 hypersensitivities to PN or components of PN were reported in these 28 articles. Reports of hypersensitivity and subsequent conclusions were based on the clinical observations made by each reporting author. These reactions were evenly split between pediatric and adult patients. Hypersensitivity to PN occurred on day of starting PN in 60.6% patients and after that time in 36.3% patients (range: 1-21 days). Of the hypersensitivities that occurred on day 1 of PN, 70% occurred in the first 30 minutes of initiation of PN. Cutaneous manifestations were the most common, followed by anaphylaxis, respiratory symptoms, and hemodynamic instability. The components most frequently identified as allergens were intravenous fat emulsion (48.4%), multivitamin solution (33.3%), and amino acid solution (9%). Based on this review, an algorithm was created to guide the practitioner on management of PN after the occurrence of such a reaction.

Prevalence, Evolution, and Risk Factors for Advanced Liver Fibrosis in Adults Undergoing Intestinal Transplantation.

Intestinal failure-associated liver disease (IFALD) occurs commonly in intestinal transplant (ITx) candidates receiving parenteral nutrition (PN). The aim of this study is to establish the prevalence and risk factors for advanced liver fibrosis in adults at the time of ITx. Retrospective chart review of all ITx was performed in adults between January 2000 and May 2014. Advanced liver fibrosis was defined as stage 3 or stage 4 fibrosis. Fifty-three patients met the inclusion criteria. The mean age was 50.6 ± 10.9 years, and the majority were female (60.4%) and Caucasian (67.9%). The mean body mass index was 21.7 ± 3.8 kg/m2 and the median duration of PN was 402 (interquartile range: 529) days. Advanced liver fibrosis at the time of ITx was found in 13 patients (24.5%). The multivariate analysis revealed that female gender and white race were significant predictors of advanced liver fibrosis. A total bilirubin >3.0 mg/dL for > a month prior to ITx was associated with an odds ratio of 8.9 for advanced fibrosis at the time of ITx but did not reach statistical significance (P = 0.055). Close to one-quarter of the ITx recipients had advanced liver fibrosis. In the current era of improved PN management, our data suggests that previously reported risk factors for IFALD, such as extreme short gut syndrome and PN duration, may have a lesser impact on development of liver fibrosis. A prolonged duration of bilirubin elevation may be associated with advanced liver fibrosis in patients with IFALD, but this requires validation in a larger cohort.