Premixed Parenteral Nutrition Research Articles

Parenteral Nutrition–Associated Liver Disease in Adult Inpatients Receiving Commercial Premixed Parenteral Nutrition for More Than 2 Weeks

AbstractBackgroundLong‐term use of parenteral nutrition (PN) may elicit complications, including PN‐associated liver disease (PNALD), which may yield critical outcomes. This study intended to investigate the development of complications associated with commercial premixed PN in adult patients.MethodsAdult patients who received nutrition support with commercial PN without enteral intake for >14 consecutive admission days were included in the analysis.ResultsSeventy‐two adults, from 2001 to 2016, were reviewed. Mean length of hospital stay was 43.0 days. A mean of 27.3 days of PN was given. Mean energy supplied by PN was 29 kcal/kg/d. Ten patients (13.8%) developed PNALD. Length of stay was significantly longer (P = .034), and duration of PN administration was significantly longer (P = .022) in patients who developed PNALD. The proportion of PN products with soybean oil–based lipids was significantly higher, and fish oil– or medium‐chain triglyceride–containing combination lipids were significantly lower in the patient group with PNALD (P = .02). Multivariate logistic regression analysis showed that longer duration of days receiving PN support was an independent risk factor for PNALD (odds ratio, 1.052; P = .029).Conclusion: The incidence of PNALD in hospitalized adult patients who received daily PN support with commercial premixed 3‐in‐1 products for >2 weeks was 13.8%. Longer duration of days receiving PN support was an independent risk factor for PNALD.

Rate of Termination of Premixed Parenteral Nutrition (PN) in Surgical Patients Secondary to High Serum Electrolytes

Rate of Termination of Premixed Parenteral Nutrition (PN) in Surgical Patients Secondary to High Serum Electrolytes

Premixed Parenteral Nutrition Solution Use in Children.

In response to national drug shortages, our institution established criteria for the use of commercial premixed parenteral nutrition (PN) solutions in select pediatric patients. Although these solutions have been marketed for use in children, there are no data in this patient population. The objective of this study was to review our use of commercial premixed PN solutions in children. This was a retrospective review of patients ≤18 years of age who received a premixed PN solution from October 2010 to April 2012. All premixed PN courses were assessed for incidence of premixed PN discontinuation due to laboratory abnormalities. Estimated goal and actual protein and total caloric intake were evaluated for premixed PN courses that were continued for >48 hours. Sixty-nine patients received 74 courses of premixed PN solutions for a mean duration of 5.6 ± 6.2 (range, 1-31) days. Fifteen courses (20%) required discontinuation of premixed PN as a result of mild laboratory abnormalities. No changes in clinical status were observed in patients and all abnormalities were corrected after switching to individualized PN. In patients receiving PN for >48 hours, premixed PN solutions provided goal protein in 48/49 (98%) courses and goal calories in 33/49 (67%) courses. Premixed PN solutions were used in a wide range of pediatric patients and provide a potential option for PN support in pediatric patients when drug shortages limit PN product supply. Close monitoring for electrolyte abnormalities and protein and caloric intake is recommended when using premixed PN solutions in children.

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.

Safety, cost, and clinical considerations for the use of premixed parenteral nutrition.

Premixed parenteral nutrition (PN) can be used for PN therapy in place of traditional compounded or customized PN. Premixed PN may have a number of advantages over compounded PN such as decreased costs, decreased compounding time, reduced chance for error, and reduced incidence of bloodstream infections. However, premixed PN may not be appropriate for all patients and may have other additional costs associated with its use. This article discusses the data available with regard to the use of premixed PN, focusing on the potential advantages and disadvantages of using premixed PN, and also discusses the implementation of premixed PN in a large tertiary cancer center.

Use of Piggyback Electrolytes for Patients Receiving Individually Prescribed vs Premixed Parenteral Nutrition

Parenteral nutrition (PN) is available as individualized prescriptions frequently prepared with an automated compounding device or as commercially prepared premixed solutions. Our institution exclusively used individualized PN until an amino acid shortage forced a temporary switch to premixed solutions. In general, premixed solutions contain lower electrolyte levels than individualized formulations prescribed for patients with normal organ function. We aimed to quantify supplemental intravenous piggyback (IVPB) electrolyte use in adult patients receiving individualized and premixed PN and to quantify any effect on difference in the cost of therapy. We compared use of supplemental IVPB electrolytes administered to patients receiving PN during consecutive periods prior to and during the amino acid shortage. Electrolyte IVPBs tabulated were potassium chloride, 10 and 20 mEq; magnesium sulfate, 2 g and 4 g; potassium phosphate, 7.5 and 15 mmol; and sodium phosphate, 7.5 and 15 mmol IVPB. There was no statistical difference in the number of PN formulations administered per day during each period (14.7 ± 3.9 vs 14.0 ± 2.6, individualized vs premixed, respectively). Total IVPB electrolytes prescribed per day increased significantly from the individualized PN period to the premixed PN period (7.03 ± 3.8 vs 13.8 ± 6.8; P < .0001). The additional IVPB electrolyte supplementation required in patients receiving premixed PN was associated with an additional $11,855.74 cost per 30 days of therapy compared with those who received individualized PN. Inpatient use of premixed PN results in a significant increase in IVPB electrolyte supplementation and cost compared with individualized PN use.

Evaluation of Efficacy and Safety of Premixed Parenteral Nutrition versus Customized Parenteral Nutrition in a Large Teaching Hospital

In the last two decades, there has been a significant degree of controversy surrounding the use of standardized parenteral solutions. Opponents of standardized parenteral nutrition claim that individualized parenteral nutrition is necessary because the critically ill patient requires daily manipulation of macro- and micro-nutrients secondary to stress associated with complex ailments. The purpose of this study was to determine if premixed parenteral nutrition solutions were equally safe and efficacious, while being less costly, in managing parenteral nutrition of patients at a large metropolitan teaching hospital, as compared to customized parenteral nutrition solutions. This was a randomized controlled trial with no placebo involving 100 patients requiring central parenteral nutrition. Consenting patients received either customized parenteral nutrition or premixed double chamber parenteral nutrition containing protein, carbohydrates and electrolytes. Vitamins and trace elements were added as needed. Each subject enrolled in the study was followed until the parenteral nutrition was either discontinued, the patient was transferred from the facility, or the patient expired during the study. Premixed and customized parenteral nutrition solutions were shown to be equally efficacious in patients as their blood glucose, fluid status, nutritional markers, serum electrolytes, phosphate, and magnesium values were within normal limits (p<.05). Premixed parenteral nutrition is associated with significantly better safety as compared to customized parenteral nutrition (11). Furthermore, the cost difference was $41,934 when comparing the premixed formulation to the customized solution. In this study, premixed parenteral nutrition solutions were equally safe, effective, and less costly than customized parenteral nutrition formulas. Patients receiving premixed parenteral nutrition experienced less adverse drug reactions and metabolic abnormalities than patients receiving customized parenteral nutrition.

Bloodstream Infections in Patients Receiving Manufactured Parenteral Nutrition With vs Without Lipids

This study compared overall bacterial and bloodstream infection rates in patients receiving premixed parenteral nutrition (PN) with vs without lipid emulsion. Data from hospitalized patients who were ≥18 years of age and receiving premixed PN between 2005 and 2007 were extracted from the Premier Perspective database. Data were categorized into 2 groups: patients who received premixed PN only and those receiving premixed PN with lipids. Multiple logistic regression was used to adjust for risk factors and potential confounders, reporting the probability of risk for an infection. The group without lipids was observed to have lower rates of both overall bacterial infection (43.5% vs 53.5%) and bloodstream infection (14.5% vs 18.9%). However, after adjusting for baseline characteristics, there were no significant differences in overall risk of bacterial infections (51.4% vs 53.5%; odds ratio [OR] = 1.11; 95% confidence interval [CI], 0.96-1.27) or bloodstream infections (19.6% vs 19.2%; 0.97; 0.81-1.16). In a subset of patients in the intensive care unit for ≥3 days, lower overall bacterial infection rates (58.3% vs 67.3%) and bloodstream infection rates (31.0% vs 37.0%) were observed in the group without lipids. After adjustment, there were no significant differences in risk of overall bacterial infection (OR = 0.95; 95% CI, 0.75-1.22) or bloodstream infection (0.92; 0.71-1.19) between the 2 groups. When administered with premixed PN, lipid emulsion was not significantly associated with an increase in the risk of infectious morbidity when compared to omitting lipids from therapy.

Nutrition therapy cost analysis in the US: pre-mixed multi-chamber bag vs compounded parenteral nutrition.

BackgroundBloodstream infections (BSI) occur in up to 350 000 inpatient admissions each year in the US, with BSI rates among patients receiving parenteral nutrition (PN) varying from 1.3% to 39%. BSI-attributable costs were estimated to approximate $US12000 per episode in 2000. While previous studies have compared the cost of different PN preparation methods, this analysis evaluates both the direct costs of PN and the treatment costs for BSI associated with different PN delivery methods to determine whether compounded or manufactured pre-mixed PN has lower overall costs.ObjectiveThe purpose of this study was to compare costs in the US associated with compounded PN versus pre-mixed multi-chamber bag (MCB) PN based on underlying infection risk.MethodsUsing claims information from the Premier Perspective™ database, multivariate logistic regression was used to estimate the risk of infection. A total of 44 358 hospitalized patients aged ≥18 years who received PN between 1 January 2005 and 31 December 2007 were included in the analyses. A total of 3256 patients received MCB PN and 41 102 received compounded PN. The PN-associated costs and length of stay were analysed using multivariate ordinary least squares regression models constructed to measure the impact of infectious events on total hospital costs after controlling for baseline and clinical patient characteristics.ResultsThere were 7.3 additional hospital days attributable to BSI. After adjustment for baseline variables, the probability of developing a BSI was 30% higher in patients receiving compounded PN than in those receiving MCB PN (16.1% vs 11.3%; odds ratio= 1.56; 95% CI 1.37, 1.79; p<0.0001), demonstrating 2172 potentially avoidable infections. The observed daily mean PN acquisition cost for patients receiving MCB PN was $US164 (including all additives and fees) compared with $US239 for patients receiving compounded PN (all differences p < 0.001). With a mean cost attributable to BSI of $US16 141, the total per-patient savings (including avoided BSI and PN costs) was $US1545.ConclusionIn this analysis of real-world PN use, MCB PN is associated with lower costs than compounded PN with regards to both PN acquisition and potential avoidance of BSI. Our base case indicates that $US1545 per PN patient may be saved; even if as few as 50% of PN patients are candidates for standardized pre-mix formulations, a potential savings of $US773 per patient may be realized.

Commercial Premixed Parenteral Nutrition: Is It Right for Your Institution?

Two-compartment premixed parenteral nutrition (PN) products are heavily promoted in the United States. These products may present safety advantages over PN solutions mixed by a local pharmacy, although clinical data to support this assertion are scarce. Multicompartment products can be labor-saving for pharmacy and therefore may be cost-effective for some institutions. Before adopting such products for use, an institution must determine that standardized PN solutions are acceptable for many or most of their patients compared with customized PN compounded specifically for individual patients. A larger selection of premixed products is available in Europe and some other parts of the world compared with the United States. Availability of a broader selection of products in the United States, including 3-compartment bags and a wider range of macronutrient concentrations and volumes, may make the use of such products more desirable in the future.