Parenteral Nutrition Prescriptions Research Articles

A cross-sectional study on the use of parenteral nutrition presciptions in patients with cancer in a tertiary hospital

Objective To investigate the application of the parenteral nutrition prescriptions for tumor patients in a tertiary hospital. Methods In this cross-sectional study, the parenteral nutrition prescriptions of all tumor inpatients in a tertiary hospital were collected from May to June in 2015. The general data of patients who had used parenteral nutrition, the types of parenteral nutrition products, as well as the ratio of energy to nirogen (E/N), glucose/lipid (G/L) ratio, non-protein energy to nitrogen ratio, and liquid volume were recorded and analyzed. Results Parenteral nutrition prescriptions were collected from 528 patients and showed high irrationality. The nutrient insufficiency rate was nearly 58.3%. The E/N (100∶1~200∶1) accounted for 32.3% and the G/L (1∶1~2∶1) 20.6%. Conclusions The rational application of parenteral nutrition should be a priority in clinical settings. A clinical nutrition supporting team may be established in tertiary hospitals to guide the appropriate use of parenteral nutrition. Key words: parenteral nutrition; prescription; prescription analysis

Trace Elements in Parenteral Nutrition: Considerations for the Prescribing Clinician.

Trace elements (TEs) are an essential component of parenteral nutrition (PN). Over the last few decades, there has been increased experience with PN, and with this knowledge more information about the management of trace elements has become available. There is increasing awareness of the effects of deficiencies and toxicities of certain trace elements. Despite this heightened awareness, much is still unknown in terms of trace element monitoring, the accuracy of different assays, and current TE contamination of solutions. The supplementation of TEs is a complex and important part of the PN prescription. Understanding the role of different disease states and the need for reduced or increased doses is essential. Given the heterogeneity of the PN patients, supplementation should be individualized.

Analysis of clinical effect of involvement of clinical pharmacists in perioperative total parenteral nutrition prescription for cancer patients

Objective To evaluate the effect of the intervention of involving clinical pharmacists in perioperative total parenteral nutrition (TPN) prescription, including rationality of prescriptions, the length of hospital stay and economic evaluation. Methods We respectively selected TPN prescriptions in September to November 2015 (pre-intervention) and December 2015 to February 2016 (post-intervention) from a surgery department of Harbin Medical University Cancer Hospital. The data regarding rationality of prescription, length of hospital stay, and economic benefit were analyzed in order to evaluate the effect of involvement of clinical pharmacists in TPN prescriptions. Results A total of 81 patients with 115 TPN prescriptions before the intervention and 92 patients with 124 TPN prescriptions after the intervention were recruited. Through comparative analysis, the rationality of TPN prescriptions increased significantly after the participation of clinical pharmacists in terms of the rational glucose: fat ratio, energy: nitrogen ratio, electrolyte concentration, and the choice of vitamin preparations; and the utilization of controversial treatments such as invert sugar and other drugs into ready-to-use TPN solution was decreased significantly; average daily cost of TPN was decreased from (1 021±218) yuan to (860±176) yuan (P 0.05). Compared with the data before the intervention, serum albumin levels after the intervention showed no statistically significant difference but pre-albumin levels were significantly higher after the participation of clinical pharmacists[(175.0±77.9)g/L vs.(153.2±64.8)g/L, P 0.05). Conclusion Engaging clinical pharmacists in TPN prescription can improve prescription rationality, ensure clinical drug safety, reduce the daily cost of nutrition treatment and thus reduce the economic burden of patients. Key words: Pharmacists; Parenteral nutrition; Inappropriate prescription; Intervention

中心静脈栄養 (TPN) 処方チェックリストを用いた薬剤師による患者モニタリング業務の有用性の評価

中心静脈栄養 (TPN) 処方チェックリストを用いた薬剤師による患者モニタリング業務の有用性の評価

CAN THE '4 P'S OF PN' IMPROVE NEONATAL NUTRIENT INTAKE?

AimsELBW infants on NICU were found to have poor growth compared to network data. Previous audit work1 showed that the time from birth to PN did not meet unit guideline...

NutritionDay ICU: A 7 year worldwide prevalence study of nutrition practice in intensive care

To determine the nutrition practice in intensive care units and the associated outcome across the world, a yearly 1 day cross sectional audit was performed from 2007 to 2013. The data of this initiative called "nutritionDay ICU" were analyzed. A questionnaire translated in 17 languages was used to determine the unit's characteristics, patient's condition, nutrition condition and therapy as well as outcome. All the patients present in the morning of the 1 day prevalence study were included from 2007 to 2013. 9777 patients from 46 countries and 880 units were included. Their SAPS 2 was median 38 (IQR 27-51), predicted mortality was 30.7%±26.9, and their SOFA score 4.5±3.4 with median 4 (IQR 2-7). Administration of calories did not appear to be related to actual or ideal body weight within all BMI groups. Patients with a BMI <18.5 or >40 received slightly less calories than all other BMI groups. Two third of the patients were either ventilated or were in the ICU for longer than 24h at nutritionDay. Routes of feeding used were the oral, enteral and parenteral routes. More than 40% of the patients were not fed during the first day. The mean energy administered using enteral route was 1286±663kcal/day and using parenteral nutrition 1440±652kcal/day. 60 days mortality was 26.0%. This very large collaborative cohort study shows that most of the patients are underfed during according to actual recommendations their ICU stay. Prescribed calories appear to be ordered regardless to the ideal weight of the patient. Nutritional support is slow to start and never reaches the recommended targets. Parenteral nutrition prescription is increasing during the ICU stay but reaching only 20% of the population studied if ICU stay is one week or longer. The nutritional support worldwide does not seem to be guided by weight or disease but more to be standardized and limited to a certain level of calories. These observations are showing the poor observance to guidelines.

Standardized Competencies for Parenteral Nutrition Order Review and Parenteral Nutrition Preparation, Including Compounding: The ASPEN Model.

Parenteral nutrition (PN) is a high-alert medication with a complex drug use process. Key steps in the process include the review of each PN prescription followed by the preparation of the formulation. The preparation step includes compounding the PN or activating a standardized commercially available PN product. The verification and review, as well as preparation of this complex therapy, require competency that may be determined by using a standardized process for pharmacists and for pharmacy technicians involved with PN. An American Society for Parenteral and Enteral Nutrition (ASPEN) standardized model for PN order review and PN preparation competencies is proposed based on a competency framework, the ASPEN-published interdisciplinary core competencies, safe practice recommendations, and clinical guidelines, and is intended for institutions and agencies to use with their staff.

Hospital Malnutrition Related to Fasting and Underfeeding: Is It an Ethical Issue?

Hospital malnutrition is a relevant clinical issue present in about 50% of patients that is associated with increased morbidity, mortality, and cost of care. Because of the relation of malnutrition with chronic and acute inflammatory processes secondary to disease, nutrition therapy is considered an important medical treatment. However, there is little discussion about the impact of another critical issue related to hospital malnutrition, that is, lack of appropriate food or nutrition therapy given to the patients. Unnecessary fasting practices and the use of inappropriate nutrition prescriptions result in underfeeding that can be a related or direct cause of hospital malnutrition, independent of disease or inflammatory state. Suboptimal prescription of oral, enteral, and parenteral nutrition should be analyzed and discussed from an ethical perspective since this practice has the potential to harm patients. In addition, absence or inadequate provision of nutrition may present barriers for improved patient outcomes and could be prevented by simply recognizing lack of knowledge, skills, or experience in nutrition and entrusting nutrition prescription to interdisciplinary teams with clinicians well prepared in nutrition sciences. This article reviews potential barriers to the prevention or treatment of hospital malnutrition and proposes specific actions that can help clinicians to overcome and implement optimal nutrition not just as medical therapy but also as a basic comfort care that may help patients nutritionally, clinically, physically, and emotionally.

Parenteral trace element provision: recent clinical research and practical conclusions.

The aim of this systematic review (PubMed, www.ncbi.nlm.nih.gov/pubmed and Cochrane, www.cochrane.org; last entry 31 December 2014) was to present data from recent clinical studies investigating parenteral trace element provision in adult patients and to draw conclusions for clinical practice. Important physiological functions in human metabolism are known for nine trace elements: selenium, zinc, copper, manganese, chromium, iron, molybdenum, iodine and fluoride. Lack of, or an insufficient supply of, these trace elements in nutrition therapy over a prolonged period is associated with trace element deprivation, which may lead to a deterioration of existing clinical symptoms and/or the development of characteristic malnutrition syndromes. Therefore, all parenteral nutrition prescriptions should include a daily dose of trace elements. To avoid trace element deprivation or imbalances, physiological doses are recommended.

Effect of a Comprehensive Total Parenteral Nutrition Training Program on Knowledge and Practice of Nurses in NICU.

Parenteral nutrition is a lifesaving therapy for many infants who are unable to tolerate enteral feedings. It fulfils preterm neonates' needs for growth and development when their sizes or conditions preclude enteral feeding. Virtuous nursing care and close biochemical monitoring are absolutely essential for successful parenteral nutrition therapy. Since poor knowledge in parenteral nutrition can causes severe impairment to neonatal infants, the conduction of this study is essential. The present study aims to: (1) examine the knowledge and practice of nurses in total parenteral nutrition (TPN); (2) employ training programs for improving knowledge and practice in management of TPN in new-borns. A quasi-experimental study was carried out in Sarem Maternity Hospital in Tehran, Iran. The study population included nurses working in Neonatal Intensive Care Unit (NICU) who were included in the study using headcount census method (n=30). A two-part questionnaire including demographic information; 20 multiple choice questions on the nurses' knowledge of TPN therapy and 19-item 3-point Likert-type checklist on administration of TPN completed by observing the nurses' practice. To examine the reliability of the practice part, Cronbach's alpha method was used (α=0.78). Study interventions were mentoring education by the researcher and researcher-developed training manual and educational video and guidelines about neonatal parenteral nutrition. Before and after intervention data were collected and compared using paired t-test. The mean scores of nurses' knowledge before and afterward parenteral nutrition (PN) training program were 11.93±1.91 and 17.56±1.59, respectively. The mean scores of the nurses' practice earlier and after training program were 38.84±2.96 and 40.15±3.02, respectively. Comparing the mean scores of the nurses' familiarity, before and after taking the training course, demonstrated a significant difference (p<0.0001). The knowledge of the nurses in all areas of parenteral nutrition prescription was significantly improved after the employment of mentoring method (p<0.05). Despite an increase in the post-intervention total score, the nurses' practice, before and after, the intervention was not statistically significant (p<0.05). There is a breach between nursing knowledge and practice in prescribing parenteral nutrition. The gap between knowledge and practice in this area can lead to more morbidity and negative influences on the infant. Therefore, it is required that the gap between knowledge and practice is known as the infant gets less damage.

Amino acid dosing in parenteral nutrition for very low birth weight preterm neonates: an outcome assessment.

This study aimed to investigate the effects of parenteral nutrition (PN) administration of amino acids (AA) on physical changes among very low birth weight infants in a local hospital setting in Malaysia. A retrospective study was carried out at a hospital in Malaysia. Records of neonates prescribed PN in the neonatal unit in 2012 were screened for eligibility. A total of 199 premature neonates received PN support in the year 2012 and, of these, 100 fulfilled the inclusion criteria. The median value of AA intake on the first day of PN was 2.00 (<28 weeks group); 1.00 (28-31 weeks group) and 0.75 (>31 weeks group). Neonates in the <28 weeks group were more likely to receive AA at an earlier time and higher initial dose compared with the other age groups. The study also found that there was no statistically significant difference in the dose of AA on the first day of PN administration and that the significant variations in nutritional parameters among the subjects did not lead to differences in physical outcomes. This study identified that when PN is provided in the local hospital setting, it is likely that the current nutritional practices are inadequate to achieve the standard growth recommendations. Our findings call for a need to optimize AA and calorie intake since growth restriction is a morbidity which will affect the infants' growth and development. Current prescriptions for PN in this hospital need to be reviewed in order to improve patient outcomes.

Parenteral Nutrition in Hospitalized Children

Objective: Parenteral Nutrition (PN) is prescribed to children with a non functioning gut or to those who fail to meet their nutritional requirements enterally. Complications should be balanced against the benefit for the patient. The aim of this study was to establish if the indications for PN prescribing in a tertiary referral children’s hospital were appropriate. Study Design: Children and newborns (infants <4 weeks of age) receiving inpatient PN between October 2013 and March 2014 were enrolled and data was collected prospectively. The appropriate indications for the use of PN were based on the 2005 guidelines by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Results: 303 children (67 newborns) were enrolled. Patients were referred from different departments across the hospital. The median duration of PN was 18 days (1-160). PN was mainly prescribed to critically ill children on intensive care (66/303), those ungergoing surgery (63/303) and bone marrow transplantation (28/303). The ESPGHAN recommendations were followed in 91.7% (278/303) of cases (newborns 64/67, 95.5%; children 214/236, 90.8%). The use of PN was considered inappropriate in 12/303 patients and in 13/303 it was not possible to reach a conclusion. Conclusion: Although the indications for inpatient PN in children is mostly justified, there is still a proportion of patients receiving intravenous nutrition unnecessarily highlighting the need for more PN training and better access to nutritional support teams.

SUN-PP013: Reimbursement Affects Prescription of Enteral and Parenteral Nutrition? Results from European Multicenter Survey

SUN-PP013: Reimbursement Affects Prescription of Enteral and Parenteral Nutrition? Results from European Multicenter Survey

Frequency and Severity of Parenteral Nutrition Medication Errors at a Large Children's Hospital After Implementation of Electronic Ordering and Compounding.

The Institute for Safe Medication Practices has stated that parenteral nutrition (PN) is considered a high-risk medication and has the potential of causing harm. Three organizations--American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), American Society of Health-System Pharmacists, and National Advisory Group--have published guidelines for ordering, transcribing, compounding and administering PN. These national organizations have published data on compliance to the guidelines and the risk of errors. The purpose of this article is to compare total compliance with ordering, transcription, compounding, administration, and error rate with a large pediatric institution. A computerized prescriber order entry (CPOE) program was developed that incorporates dosing with soft and hard stop recommendations and simultaneously eliminating the need for paper transcription. A CPOE team prioritized and identified issues, then developed solutions and integrated innovative CPOE and automated compounding device (ACD) technologies and practice changes to minimize opportunities for medication errors in PN prescription, transcription, preparation, and administration. Thirty developmental processes were identified and integrated in the CPOE program, resulting in practices that were compliant with A.S.P.E.N. safety consensus recommendations. Data from 7 years of development and implementation were analyzed and compared with published literature comparing error, harm rates, and cost reductions to determine if our process showed lower error rates compared with national outcomes. The CPOE program developed was in total compliance with the A.S.P.E.N. guidelines for PN. The frequency of PN medication errors at our hospital over the 7 years was 230 errors/84,503 PN prescriptions, or 0.27% compared with national data that determined that 74 of 4730 (1.6%) of prescriptions over 1.5 years were associated with a medication error. Errors were categorized by steps in the PN process: prescribing, transcription, preparation, and administration. There were no transcription errors, and most (95%) errors occurred during administration. We conclude that PN practices that conferred a meaningful cost reduction and a lower error rate (2.7/1000 PN) than reported in the literature (15.6/1000 PN) were ascribed to the development and implementation of practices that conform to national PN guidelines and recommendations. Electronic ordering and compounding programs eliminated all transcription and related opportunities for errors.

Standardized Competencies for Parenteral Nutrition Prescribing: The American Society for Parenteral and Enteral Nutrition Model.

Parenteral nutrition (PN) provision is complex, as it is a high-alert medication and prone to a variety of potential errors. With changes in clinical practice models and recent federal rulings, the number of PN prescribers may be increasing. Safe prescribing of this therapy requires that competency for prescribers from all disciplines be demonstrated using a standardized process. A standardized model for PN prescribing competency is proposed based on a competency framework, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)-published interdisciplinary core competencies, safe practice recommendations, and clinical guidelines. This framework will guide institutions and agencies in developing and maintaining competency for safe PN prescription by their staff.

PTH-193 Time to prescribe? an audit of the management of patients on parenteral nutrition

Introduction The Allied Health Professionals prescribing and medicines supply mechanisms scoping project report identified an evidence base for extending prescribing rights to dietitians based on improved patient safety and experience, effectiveness and value and clear clinical responsibility. 1 Currently at our Trust the dietitian completes the nutritional assessment and calculates requirements for patients requiring parenteral nutrition (PN) and then a doctor signs the prescription. This means that the doctor is taking legal responsibility for another healthcare professional’s assessment which has implications for patient safety. The aim of this audit was to identify who completed the nutritional assessment, calculated requirements and decided on the composition of the PN prescription and formulation and who signed the legal prescription. Method This was a point prevalence audit at a tertiary referral centre for intestinal failure. All patients receiving PN were included and a questionnaire regarding the healthcare professionals involved in the assessment and the decision regarding the prescription of the PN was completed. Results Twenty-seven patients were on PN on the day of the audit. Ten patients were on a surgical ward and 17 were on a medical ward. The initial nutritional assessment and calculation of requirements was completed by a dietitian in 100% of cases. Nine patients (33%) were considered at risk of refeeding syndrome but none developed refeeding. In 89% of cases (n = 24) the legal prescription was signed by a junior doctor. Of these 24 patients the doctor was directly involved in the patients nutritional care in only 7 cases (29%). Over the previous 7 days amendments to the PN were made by the dietitian alone (n = 14), the dietitian and doctor (n = 4), the dietitian and pharmacist (n = 2). Nineteen patients were also receiving oral diet, 2 were on trophic enteral nutrition and 6 were nil by mouth. Conclusion This audit has shown that at this tertiary referral centre the dietitian is responsible for completing the nutritional assessment and calculating requirements for patients requiring PN including the prevention of refeeding syndrome. Ongoing monitoring of the patient occurs in conjunction with other members of the nutrition team. Previous work showed a dietitian and pharmacist working together are safe to prescribe and manage PN. 2 Supplementary prescribing would enable dietitians to work in conjunction with pharmacists to take clinical and legal responsibility for the PN they are recommending instead of asking junior doctors to take on responsibility for their clinical decisions. This is likely to save doctors time and improve patient safety. Disclosure of interest None Declared. References Marks D. Allied Health Professionals prescribing and medicines supply mechanisms scoping project report. Department of Health, 2009 Farrer K et al . Pharm J 2008;280:626

Use of Premixed Parenteral Nutrition During a Phosphate Shortage in a Non-Critically Ill Population.

Drug shortages pose prescribing problems to clinicians. During fiscal year (FY) 2014, an acute shortage of intravenous potassium phosphate (K-Phos IV), a common supplement in parenteral nutrition (PN), prompted the use of premixed instead of individualized PN to conserve K-Phos IV. Here we quantify the K-Phos IV conserved by using premixed PN and the associated cost differences. Costs of preparing premixed PN vs individualized PN of equivalent composition were calculated for FY 2014 at a single-center tertiary care facility. Quantity and cost of K-Phos IV saved were calculated based on the number of premixed PN prescriptions. Costs for FY 2015 were projected based on drug costs from July 2014. During FY 2014, prescribing premixed in lieu of individualized PN conserved 16,440 mmol K-Phos IV but increased the cost of PN by $4080.45. However, increases in K-Phos IV cost at the end of FY 2014 resulted in premixed PN as a relatively less expensive therapy than individualized PN for our institution. Cost savings of $7092.20 due to use of premixed PN is projected for FY 2015. Prescribing premixed PN conserves K-Phos IV during shortages, but it increased direct drug spending in non-critically ill patients at our institution during FY 2014. Persistent shortages can drive market costs of K-Phos IV, however, necessitating frequent reconsideration of resource utilization.

Step towards Multiplatform Framework for Supporting Pediatric and Neonatology Care Unit Decision Process

Abstract Children are an especially vulnerable population, particularly in respect to drug administration. It is estimated that neonatal and pediatric patients are at least three times more vulnerable to damage due to adverse events and medication errors than adults are. With the development of this framework, it is intended the provision of a Clinical Decision Support System based on a prototype already tested in a real environment. The framework will include features such as preparation of Total Parenteral Nutrition prescriptions, table pediatric and neonatal emergency drugs, medical scales of morbidity and mortality, anthropometry percentiles (weight, length/height, head circumference and BMI), utilities for supporting medical decision on the treatment of neonatal jaundice and anemia and support for technical procedures and other calculators and widespread use tools. The solution in development means an extension of INTCare project. The main goal is to provide an approach to get the functionality at all times of clinical practice and outside the hospital environment for dissemination, education and simulation of hypothetical situations. The aim is also to develop an area for the study and analysis of information and extraction of knowledge from the data collected by the use of the system. This paper presents the architecture, their requirements and functionalities and a SWOT analysis of the solution proposed.

PO-0607a The Benefit Of Computer Assisted Prescription Of Parenteral Nutrition In Elgans

Background To minimise extrauterine growth restriction in ELGANs computer assisted prescription of parenteral nutrition (CAPPN) was introduced. Aim To evaluate the effectiveness of CAPPN in growth improvement of ELGANs. Patients and methods In this retrospective, observational designed study with a nonprobability, convenience sampling to obtain medical records, we compared 20 ELGANs in the study group after CAPPN to 20 ELGANs in the control group before CAPPN. Daily parenteral and enteral intake of macronutrients, calcium and phosphate in five sequetial time intervals of the first 28 days of life was calculated (day 1–3, 4–7, 2nd, 3rd, 4th week). Outcome measures were the lenght of PN, days to regain birth weight (BW), growth velocity, and weight and head circumpherence (HC) Results The combined enteral and parenteral intake of the study group in all five sequential intervals after birth exceeded the intake of the control group. The lenght of PN and days to regain BW did not differ, however growth velocity (14,5 [3,7] vs 11.6 [0,4] g/day (p = 0.03)) and HG velocity (0.9 [0.3] vs 0.7 [0.4] cm/day (p = 0.03)) were higher in the study group. Less growth retardation on day 28 was obtained (weight 2/20 vs 9/20 (p Conclusion In ELGANs delivery of nutrients and growth during the first month of life were significantly improved with CAPPN.

How to feed complicated patients after surgery: what's new?

This clinical review focuses on the nutritional management of surgical patients with a severe postoperative complication. These patients having a succession of aggressions are at high risk of malnutrition. Our aim, following ICU patient studies, was to report the elements that could be applied for these patients. Although early enteral nutrition is recommended, recent data focus more on parenteral nutrition. Because these patients probably had a poor nutritional intake for several days, the prescription of parenteral nutrition would appear to be valid in cases of inadequate or impossible enteral nutrition. Lipid emulsion decreasing long-chain triglyceride intake should be used. Moreover, administration of fish oil should be considered. Intravenous glutamine, decreasing new infections and hospital length of stay, should be prescribed only in patients without shock. Several studies and meta-analyses have suggested that a parenteral selenium supplementation in a severe patient can reduce mortality. In severe surgical complicated patients, special care must be taken vis-à-vis nutritional intake. Such patients are likely to have an energy deficit and are at high risk of malnutrition. Nutritional assistance is necessary and should be quickly implemented with the usual recommendations.