Parenteral Nutrition Solutions Research Articles

Micronutrients in Parenteral Nutrition: Boron, Silicon, and Fluoride

Boron may be beneficial for bone growth and maintenance, central nervous system function, and the inflammatory response, and silicon may be beneficial for bone maintenance and wound healing. Fluoride is not an essential element but amounts provided by contamination may be beneficial for bone strength. Fluoride toxicity may be a concern in parenteral nutrition. Further studies are warranted to determine whether there are optimal amounts of boron and silicon that should be delivered to typical and special population patients receiving parenteral nutrition. In addition, further studies are needed to determine whether providing the dietary guideline of adequate intake amounts of fluoride parenterally would prevent or treat parenteral nutrition osteopenia.

Chromium in Parenteral Nutrition: Too Little or Too Much?

Although guidelines for routine parenteral supplements of chromium (Cr) were published, there remain major concerns about the infusion of excess Cr. In addition, little information is available on appropriate dosage for intravenous usage. Cr functions as a regulator of insulin action. In humans, the 3 reported cases of Cr deficiency developed peripheral neuropathy, weight loss, and hyperglycemia. Supplementation of Cr to the parenteral nutrition (PN) solution corrected these abnormalities. For parenteral Cr, concerns arise from the high levels found in sera (up to 40-fold higher) and tissues (10- to 100-fold higher) and their effects on kidneys: In 15 children receiving long-term PN, the glomerular filtration rate was lower than that of non-PN controls and was inversely correlated with Cr indices. Furthermore, in a randomized blinded prospective protocol involving 75 newborns, the group receiving the recommended dose of Cr showed higher levels of creatinine that were positively correlated with Cr intake. Of note, Cr contaminants in PN solutions can increase the amount delivered by 10%-100%. A possible method for estimating adequate Cr to be provided IV is to calculate the amount physiologically absorbed in healthy people. This amount is 10 to 100 times less than the daily recommended parenteral Cr in adults. The accumulated scientific data presented here point to a serious need to lower the recommended amount of parenteral Cr.

The Addition of Choline to Parenteral Nutrition

Choline is a quaternary amine endogenously synthesized from the amino acid methionine or absorbed via the portal circulation. It is ubiquitous in the diet, although it has a greater presence in organ meats. Choline is an essential component of all cell membranes, and has been considered a required dietary nutrient since 1998 by the US Institute of Medicine's Food and Nutrition Board. Choline is necessary for DNA repair, mediated by its role as a methyl donor. It also serves as the precursor for the neurotransmitter acetylcholine. Evidence has accumulated that hepatic steatosis, which occurs during parenteral nutrition therapy, develops as a result of choline deficiency because endogenous production of choline from parenterally infused methionine is deficient. In addition, memory deficits and skeletal muscle abnormalities have been described, and choline deficiency appears to activate cellular apoptosis. Provision of intravenous choline ameliorates hepatic steatosis associated with parenteral nutrition infusion.

Manganese in Parenteral Nutrition: Who, When, and Why Should We Supplement?

Micronutrient requirements are not fully understood. Parenteral nutrition (PN) usually contains the trace element (TE) manganese (Mn) from fixed-concentration TE supplements. Multiple TE formulations may not be optimal in pediatric and home PN. Moreover, most PN products contain Mn as a ubiquitous contaminant. Excessive Mn can lead to Parkinson-like symptoms resulting from hypermanganesemia. A survey of 40 Australasian hospitals that contributed data on 108 patients to the annual home PN register and a systematic review of the literature were conducted to establish the scope of the potential problem of Mn toxicity in PN patients. Exposure to Mn doses 5-6 times current daily requirements, together with the TE contamination that is reported in PN products, can lead to neurotoxicity. Whole-blood levels are more accurate for monitoring and correlate well with signal intensity of magnetic resonance imaging. Current TE formulations restrict prescribing options. The regulatory mechanisms of Mn homeostasis are bypassed via the parenteral route so elimination via the hepatobiliary system is impaired, resulting in tissue or brain accumulation. Published dosage recommendations may be excessive and official guidelines require revision. Variability in clinical practices necessitates that individual TE additives are more widely available and multiple TE products reformulated. More frequent monitoring for any brain accumulation is recommended. The scarcity of PN-associated Mn deficiency, plus the growing evidence for Mn toxicity, leads to the conclusion that it is unnecessary for Mn to be prescribed routinely for pediatric or long-term PN patients.

Utilisation des solutés standard pour l’alimentation parentérale du nouveau-né en France – Résultats d’une enquête nationale

Standard parenteral nutrition solutions have been developed nationwide in France but little is known about their frequency of use and indications. To evaluate the frequency of the use of standardized parenteral nutrition solutions in neonatal units in France, to determine which solutions are currently available and used, and to determine whether the available parenteral nutrition solutions are satisfactory to the prescriber by evaluating the type and number of additions most frequently prescribed. National survey performed in France, using a questionnaire sent to 296 French neonatal departments. Eighty-five percent of level III units and 50% of the level II units responded to the questionnaire. Standardized parenteral nutrition solutions were used in 66% of the responding units and accounted for 45% of the prescriptions of parenteral nutrition in newborns. They were significantly more frequently prescribed by level II than level III units (68% vs. 24%, p<0.0001). Thirteen of the 40 standard solutions declared as solutions for parenteral nutrition did not contain amino acids. The addition of macro- and/or micronutrients was very frequent and often made even if not indicated in the Consumer Medicine Information (CMI). There is great heterogeneity in parenteral nutrition practices among French neonatal units. A large number of the standard solutions used are not appropriate for the nutrition of full-term and/or preterm infants. Their use in everyday practice does not cover the nutritional needs of the newborn or induces at-risk practices such as supplementation with macro- and/or micronutrients.

Compatibility and efficiency of iron in parenterai nutrition admixtures

Iron is used to treat microcytic hypochromic anemia due to iron deficiency.Parenteral iron therapy is necessary for patients whose oral route of administration is unavailable or ineffective.Iron supplementation via parenteral nutrition solutions has been used in some patients.However,the addition of iron to parenteral nutrition mixtures may lead to precipitation as a result of incompatibilities and/or degradation.Factors influencing the compatibility,stability,and efficiency of iron in parenteral nutrition admixtures are summarized. Key words: Iron; Iron deficiency anemia; Stability; Total nutrient admixture

Phosphorus levels during infusion of parenteral nutrition with calorie-based phosphorus concentration: A case series

Summary Background & aims Hypophosphatemia occurs frequently in patients on parenteral nutrition, mainly when malnutrition is present, and is related to phosphorus concentration in the solution. In spite of hypophosphatemia's potentially fatal outcome, there is no consensus on the adequate concentration of phosphorus in parenteral nutrition solutions. Increasing phosphorus concentration in the solution has not decreased the disorder, causing hyperphosphatemia instead. This study aims to evaluate blood phosphorus balance during infusion of a parenteral solution with a phosphorus concentration based on total energy. Methods Thirty-six non-critically ill patients (50% male, 36% undernourished, 51.4 ± 17.2 years) received total parenteral nutrition with phosphorus concentration varying from 9.6 to 10 mMol per 1000 kcal. Blood samples for serum phosphorus levels were collected in three periods up to the seventh day of nutritional treatment. Only moderate and severe hypophosphatemia with levels below 2.2 mg/dl were considered. Clinical data and laboratory values had normal distribution and were analyzed with Chi-square for proportions and by ANOVA for repetitive measures. Results The incidence of hypophosphatemia was 11.1% (95% CI 4.5–25%) initially, 5.9% (95% CI 1.7–18%) in the second period (3rd to 4th day) and 5.3% (95% CI 1.0–16%) in the third period (5th to 7th day) (p = N.S.). Median phosphorus levels were 3.35 mg/dl (95% CI 2.7–3.4 mg/dl), 3.2 mg/dl (95% CI 2.9–3.6 mg/dl) and 3.1 mg/dl (95% CI 2.9–3.7 mg/dl), in these three periods respectively, without a statistically significant difference (p = N.S.). No adverse events associated with phosphorus disturbances were observed throughout parenteral nutrition therapy. Conclusions Phosphorus concentration from 9.6 to 10 mMol/1000 kcal in parenteral nutrition resulted in lower than expected rates of hypophosphatemia in non-critically ill patients with no significant side effects related to this phosphorus concentration.

Use of Di(2-Ethylhexyl)Phthalate–Containing Infusion Systems Increases the Risk for Cholestasis

Most polyvinylchloride infusion systems are plasticized with up to 60% of di(2-ethylhexyl)phthalate (DEHP). DEHP is easily extracted from the tubing by total parenteral nutrition (TPN) solutions and has been shown to have toxic effects on various organ systems including the liver in animals and humans. A role was postulated for DEHP in the development of hepatobiliary dysfunction in premature and newborn infants receiving parenteral nutrition, and the incidence of cholestasis was investigated after changing from polyvinylchloride infusion systems to polyvinylchloride-free infusion systems. Two 3-year periods from 1998 to 2004 were investigated retrospectively before and after changing from polyvinylchloride to polyvinylchloride-free infusion systems in our department. This resulted in 1 group of 30 patients treated with polyvinylchloride lines and a second group of 46 patients treated with polyvinylchloride-free lines. The 2 groups were examined for the incidence of cholestasis and other possible contributing factors. Statistics were performed by using SAS software (SAS Institute, Cary, NC). After changing infusion systems, the incidence of cholestasis dropped from 50% to 13%. Using DEHP-plasticized polyvinylchloride infusion systems for TPN increased the risk for cholestasis by a factor of 5.6. The use of polyvinylchloride lines correlated strongly with the development of TPN-associated cholestasis (P = .0004). Using DEHP-containing polyvinylchloride infusions systems contributes to the development of cholestasis. Therefore, the use of DEHP-free infusion systems for TPN is recommended, especially in premature and newborn infants.

Low Availability of Aluminum in Formulations for Parenteral Nutrition Containing Silicate

Silicate (Si) and aluminum (Al) may be concomitant impurities in solutions for parenteral nutrition (PN). Silicate can bind to Al to form stable hydroxyaluminosilicates (HAS), thus reducing Al availability. This possibility is investigated by heating solutions containing constituents of PN in glass containers to promote the release of Si and Al. The total amount of Si and Al in solution is measured by atomic absorption spectrometry, and the Al not bound to Si is evaluated by reaction with morin. When the Si:Al molar ratio is >5, no free Al is found in solution. For ratios <5, it is found that the lower the ratio, the higher the free Al fraction. However, in solutions of some amino acids, even with a low Si:Al ratio (<2), the amount of free Al is lower than that found in other solutions. The same tendency is observed among commercial formulations. Although in salt solutions the free fraction of Al reaches almost 100% when the Si concentration is low, in amino acid formulations the free fraction of Al does not surpass 50%. Moreover, even for Si:Al ratios >5, there is a "residual" fraction of free Al in amino acid formulations. The concomitant presence of Al and Si in solutions for PN reduces the amount of Al available attributable to the formation of HAS. In amino acid formulations this effect may be slightly reduced given the affinity of certain amino acids for Al. Therefore, amino acids may behave in the same fashion as silicate.

Aluminium exposure from intravenous feeding solutions and later bone health: 15 year follow-up of a randomised trial in preterm infants

Background: Aluminum has known neurotoxicity and may impair short-term bone health. In a randomised trial we showed reduced neurodevelopmental scores in preterm infants previously exposed to aluminum from parenteral nutrition solutions. Here, in the same cohort, we test the hypothesis that neonatal aluminum exposure also adversely affects long-term bone health, as indicated by reduced bone mass. Methods: Bone area (BA) and bone mineral content (BMC) of lumbar spine, hip and whole body were measured with Dual X-ray Absorptiometry (DXA) in 13-15yr olds who were born preterm and randomly assigned standard or aluminum-depleted parenteral nutrition (PN) solutions during the neonatal period. Results: 59 subjects (32% of survivors) were followed. Those randomised to standard PN solution had lower lumbar spine BMC; apparently explained by a concomitant decrease in bone size. In non-randomised analyses, subjects exposed to neonatal aluminum intakes above the median (55mcg/kg) had lower hip BMC (by 7.6% (95% CI 0.21 to 2.38; p=0.02)), independent of bone (or body) size. Conclusion: Neonates exposed to parenteral aluminum may have reduced lumbar spine and hip bone mass during adolescence, potential risk factors for later osteoporosis and hip fracture. These findings need confirmation in larger, more detailed studies. Nevertheless, given our previous finding of adverse developmental outcome in these subjects, and the sizeable number of contemporary infants undergoing intensive neonatal care who are still exposed to aluminum via parenteral feeding solutions, the potential adverse long term consequences of early aluminum exposure now deserve renewed attention.

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.

RAPID DEVELOPMENT OF VITAMIN K DEFICIENCY IN AN ADOLESCENT BOY RECEIVING TOTAL PARENTERAL NUTRITION FOLLOWING BONE MARROW TRANSPLANTATION

In this case report the development of a vitamin K deficiency in a neutropenic adolescent receiving parenteral nutrition following bone marrow transplantation is described. The parenteral nutrition solution did not provide vitamin K and the patient had been receiving oral antibiotics prior to and during use of the intravenous feeding. Oral intake was minimal. Standard adult oral and intravenous multivitamin preparations for use in individuals older than 11 years do not routinely contain this vitamin. The function of vitamin K and causes for development of a deficiency are reviewed. Recommended intakes and guidelines for supplementation are also discussed.

Glutamine in parenteral solutions enhances intestinal mucosal immune function in rats.

Biliary secretory immunoglobulin A (sIgA) and proportions of IgA+ plasma cells, helper T cells, and suppressor/cytotoxic T cells in intestinal tissue were lower in rats receiving a standard total parenteral nutrition (TPN) solution than in those receiving TPN enriched with glutamine. Parenteral solutions supplemented with glutamine may preserve the ability of intestinal immune tissue to produce sIgA-synthesizing plasma cells following antigenic stimulation.

Supplementation of total parenteral nutrition solutions with ferrous citrate.

Supplementation of Total Parenteral Nutrition Solutio with Ferrous Citrate Get access Nutrition Reviews, Volume 43, Issue 1, January 1985, Pages 20–22, https://doi.org/10.1111/j.1753-4887.1985.tb02387.x Published: 01 January 1985

Glutamine: a conditionally essential nutrient or another nutritional puzzle.

Malnutrition and infection are common among patients receiving bone marrow transplant. A recent randomized, double-blind study was conducted to determine whether the addition of glutamine to standard total parenteral nutrition solutions would improve nitrogen retention and reduce hospital morbidity in a group of 45 bone marrow transplant patients. The results showed improved nitrogen balance and reduced incidence of clinical infection in the glutamine-supplemented patients.

Increased Oxidants and Reduced Antioxidants in Irradiated Parenteral Nutrition Solutions May Contribute to the Inflammatory Response

To measure reactive oxidant production and the decline in antioxidant potential in commercially available, irradiated parenteral nutrition (PN) solutions and the effect that these have on oxidant production in patients in the intensive care unit. Vitamin E and malondialdehyde in irradiated and nonirradiated commercially available, PN solutions were measured. The PBN (alpha-phenyl-n-test-butylnitrone (PBN) spin trap was used to measure free radicals and TEMPOL (2,2,6,6-tetramethyl-4-hydroxy-piperidine-oxyl) was used to assess antioxidant capacity. The irradiated PN was administered (as per unit protocol) to 10 patients with gut failure and plasma and urinary isoprostanes and interleukin-6 (IL-6) were measured 1 hour preadministration, at the time of, and 1 and 2 hours postadministration of PN. Irradiation reduced vitamin E significantly (P < .0025). Malondialdehyde products were present in both samples, but more so in irradiated samples (P < .0001), as were free radicals measured by PBN spin trapping. Irradiated samples had a higher scavenging capacity of TEMPOL free radical due to depletion of antioxidants in irradiated samples. Urinary isoprostanes increased at time 2 by 6.3 units relative to time 0 and by 5.23 units relative to time 1(Friedman ANOVA: P < .01413). Lipid hydroperoxides are formed in PN solutions and increase further following irradiation. This is associated with a significant reduction in vitamin E and antioxidant potential. The increase in urinary isoprostanes indicates a potentially proinflammatory effect of irradiated PN.

Need for Thiamine in Peripheral Parenteral Nutrition After Abdominal Surgery in Children

Thiamine blood concentrations of pediatric patients receiving peripheral parenteral nutrition change during the postoperative period. In addition, the need to administer thiamine after surgery has not yet been fully studied in children receiving peripheral parenteral nutrition. The objective of this prospective study is to clarify whether pediatric patients require the administration of thiamine while receiving peripheral parenteral nutrition after abdominal surgery. Fifteen children were divided into 2 groups; 1 group received peripheral parenteral nutrition without thiamine after surgery (n = 7), whereas the other group received peripheral parenteral nutrition with thiamine after surgery (n = 8). In both groups, thiamine blood concentrations were measured on the preoperative day, and changes in thiamine concentration over time were measured during the starvation period from the first to the fifth postoperative day. Preoperative thiamine blood concentrations were within the normal range in both groups. In the group receiving peripheral parenteral nutrition without thiamine, the thiamine concentration gradually decreased with time after the operation, whereas the concentration remained within the normal range in the group receiving peripheral parenteral nutrition with thiamine. Among the 7 patients receiving peripheral parenteral nutrition without thiamine, the thiamine concentration in 3 patients was below the normal range on the fifth postoperative day. During the starvation period after abdominal surgery, thiamine blood concentrations decreased in pediatric patients receiving peripheral parenteral nutrition without thiamine. Therefore, clinicians treating pediatric patients should add thiamine to the peripheral parenteral nutrition solution during the short starvation period after abdominal surgery.

各種輸液剤の滴容量と変動要因

In parenteral nutrition,each intravenous solution has an optimum infusion rate and proper management of administration is a very important issue.In the case of not using an infusion pump (gravity infusion) and using an infusion pump which controls the number of droplets,the administered volume depends on the droplet size,i.e.droplet volume.While the Ministry of Health,Labour and Welfare (Bulletin No.112)specifies the number of droplets per mL for intravenous administration sets,there is a lack of information on how the physical characteristics of solutions affect droplet volume.Therefore,in the present study,we investigated droplet volume for various intravenous solutions during administration and found that the solution density,surface tension (solutions with and without surfactants),and infusion rate all affect droplet volume.

Threonine requirement of parenterally fed postsurgical human neonates

BackgroundThe threonine requirement of human neonates who receive parenteral nutrition (PN) has not been determined experimentally. ObjectiveThe objective was to determine the parenteral threonine requirement for human neonates by using the minimally invasive indicator amino acid oxidation technique with l-[1-13C]phenylalanine as the indicator amino acid. DesignNine postsurgical neonates were randomly assigned to 16 threonine intakes ranging from 10 to 100 mg · kg−1 · d−1. Breath and urine samples were collected at baseline and at plateau for 13CO2 and amino acid enrichment, respectively. The mean threonine requirement was determined by applying a 2-phase linear regression crossover analysis to the measured rates of 13CO2 release (F13CO2) and l-[1-13C]phenylalanine oxidation. ResultsThe mean threonine parenteral requirement determined by using phenylalanine oxidation was 37.6 mg · kg−1 · d−1 (upper and lower confidence limits, respectively: 29.9 and 45.2 mg · kg−1 · d−1) and by using F13CO2 oxidation was 32.8 mg · kg−1 · d−1 (upper and lower confidence limits, respectively: 29.7 and 35.9 mg · kg−1 · d−1). Graded intakes of threonine had no effect on phenylalanine flux. ConclusionThis is the first study to report on the threonine requirement for human neonates receiving PN. We found that the threonine requirement for postsurgical PN-fed neonates is 22–32% of the content of threonine that is presently found in commercial PN solutions (111–165 mg · kg−1 · d−1).

Epidemiology of bloodstream infection associated with parenteral nutrition

Catheter-related bloodstream infections (CR-BSIs) occur in 1.3% to 26.2% of patients with central venous catheters used to administer parenteral nutrition (PN). Because of their nutritional components, PN solutions can support microbial growth. Contamination during preparation and handling is rare in hospitals and home-infusion pharmacies but may be difficult to control in a home setting. The risk of infection is increased in hospitalized patients because of malnutrition-associated immunosuppression, hyperglycemia exacerbated by dextrose infusion, microbial colonization/contamination of catheter hubs and the skin surrounding insertion site, and poor nursing care. During long-term catheter use for PN, an intraluminal biofilm, catheter-tip fibrin sheath or tail, or central venous thrombosis creates sites for microbial seeding and infection. Chronic conditions and psychosocial issues also increase the risk of infection. In hospitalized patients with BSIs, the most common organisms are coagulase-negative staphylococcus, Staphylococcus aureus, Enterococcus, Candida spp, Klebsiella pneumoniae, and Pseudomonas aeruginosa. In the long-term PN population, approximately 60% of CR-BSIs are caused by coagulase-negative Staphylococcus. The best plan of care for a suspected or known infected catheter in a hospitalized patient is to reinsert a new central line after 48 hours of antibiotic treatment and negative blood cultures. In patients who receive long-term PN, hospitalization increases the risk of a nosocomial infection because the catheter can be contaminated by staff. A patient with fungemia must always be admitted and catheter removed. With gram-positive and gram-negative organisms, the catheter may not need to be removed. In most patients receiving PN at home, removing a long-term venous-access device is challenging. Peripheral vein access or peripherally inserted central catheters are needed until a new permanent device can be inserted after negative blood cultures are obtained. Evaluation of remote site infection also is necessary. Strategies to reduce or prevent infection include catheter lock therapy, daily evaluation of continued need for PN, enteral rather than PN support, and avoiding overfeeding. More studies are needed to demonstrate conclusively the benefits of immunonutrition, such as the use of omega-3 or glutamine supplements to reduce CR-BSIs in patients receiving PN.