Provision Of Parenteral Nutrition Research Articles

Parenteral nutrition for patients with advanced ovarian malignancy

Parenteral nutrition (PN) in patients with disseminated ovarian cancer remains controversial. The role of PN in providing nutrition and improving quality of life is unclear. The present study aimed to determine the pattern of prescribing in a large teaching hospital, and to identify subgroups where the use of PN was justified. Sixty-five patients with advanced ovarian carcinoma received PN between January 2002 and May 2008. A retrospective case note review was undertaken to retrieve data on PN prescribing and outcomes in terms of duration of PN provision, complications, and survival. Three subgroups were identified. Group I consisted of 18 (28%) patients who received PN for a median [interquartile range (IQR)] of 5 (2-11) days. The majority of these 18 patients (n = 13, 72%) had disease-related terminal bowel obstruction. Out of 18 of these patients, 17 (95%) had poor performance status. The median (IQR) survival was 12 (6-28) days. Group II consisted of 40 (61%) patients who were re-established on enteral nutrition. The median (IQR) duration of PN administration was 10 (6-17) days. The most common indication of PN was protracted ileus (n = 25, 63%). Out of 40 of these patients, 35 (88%) patients had good performance status. The median (IQR) survival was 264 (96-564) days. The third group of patients required home PN (n = 7, 11%). Four (58%) patients had short bowel syndrome and three (42%) had terminal intestinal obstruction. All of the patients had good performance status. The median (IQR) duration of PN administration and survival was 241 (90-305) days. Administration of PN appears to be justified in those patients with a good performance status (i.e. patients capable of self-care), which constituted three-quarters of this cohort. In the remaining patients with poor performance status, and particularly those with terminal intestinal obstruction, PN administration was difficult to justify. PN should not be denied based purely on the pathology, although cautious judgment is required to select those who are most likely to benefit.

The provision of parenteral nutrition: it's not in the bag

The administration of parenteral nutrition is a well-established technique providing nutritional support to patients who have an inaccessible or non-functioning gut (intestinal failure). As such it is widely used by surgeons, intensivists, paediatricians, neonatologists, oncologists and clinical nutrition specialists. However, it is available to all clinicians regardless of specialty or expertise in its use.

Combining enteral with parenteral nutrition to improve postoperative glucose control

The provision of parenteral nutrition (PN) to 'stressed' patients often results in hyperglycaemia, which may be detrimental. In animal models limited amounts of enteral nutrition (EN) improve intestinal integrity and stimulate intestinal incretin production, which may lead to improved glucose control. We set out to assess if combining EN with PN results in improved glucose homeostasis rather than PN given alone. We conducted a randomised trial in a university teaching hospital of patients undergoing a 'curative' oesophagectomy for adenocarcinoma. Differences between the two intervention groups were assessed for continuous glucose measurement, insulin sensitivity using insulin tolerance tests (ITT) and homeostasis model analysis (HOMA), the incretin glucose-dependent insulinotropic polypeptide (GIP) and intestinal permeability. The combination of PN with EN resulted in lower interstitial glucose concentrations (P = 0.002), reduced insulin resistance, improved insulin sensitivity (HOMA-insulin resistance (IR) P = 0.045; HOMA beta P = 0.037; ITT P = 0.006), improved intestinal permeability (P < 0.001) and increased GIP (P = 0.01) when compared with PN alone. The combination of EN with PN, when compared with PN alone, results in reduced glucose concentrations, reduced insulin resistance, increased incretins and improvements in intestinal permeability.

Safe parenteral nutrition and the role of standardised feeds

Workload pressure on pharmacies through increased demands for parenteral nutrition (PN) is leading to a growing trend in the use of commercially manufactured PN (‘standard feeds’) and away from individually ‘tailored’ prescriptions. This is sometimes justified on grounds of safety, although many areas of risk remain inherent in the process of PN provision. In fact there is little to suggest that widespread introduction of standard feeds would do much to further reduce the already low frequency of serious adverse events. The relative clinical benefits of providing standard feeds or tailored feeds have not been adequately studied, making it impossible to give a clear endorsement of one system over the other. It seems probable that for a proportion of stable patients a range of standard feeds could provide adequate nutritional support, while in unsta-ble patients with complex needs and those needing long term PN, tailored feeds appear the more logical choice. Pharmacy compounding units, therefore, need to remain flexible in their approach to PN provision. Since even small variations in nutrient intake in early life may have long lasting implications for extremely premature infants the processes of formulating and providing PN deserve further study.

Economic analysis model for inpatient parenteral nutrition: A pilot study

AbstractAim: Parenteral nutrition is a high‐cost but essential support service in contemporary health care, yet no model exists to determine the total cost. This study aimed to create a cost analysis model identifying both direct and indirect costs of parenteral nutrition inpatient care.Methods: A health economics analysis model was constructed and used to create an audit tool for measuring parenteral nutrition costs in seven predefined categories. This tool was piloted on a cohort of 21 consecutive patients commencing parenteral nutrition at a large city hospital between March and April 2008. These patients were prospectively audited for a maximum 12 days or until parenteral nutrition cessation (192 patient days). Costs and adherence to evidence‐based guidelines were compared across the seven categories and between patient subgroups determined by ward locality upon commencement.Results: The mean total cost for all parenteral nutrition patients was $1579(NZD)/day, of which non‐parenteral hospital costs comprised 85%. For patients treated solely outside the intensive care unit, cost was $1045 per day, of which 24% was directly attributed to provision of parenteral nutrition. Formula accounted for nearly two‐thirds (63%) of parenteral nutrition direct costs and 8.5% of that prescribed was wasted. Return to oral or enteral nutrition was achieved in 57% patients within 12 days of commencing parenteral nutrition.Conclusions: Direct costs involved in providing parenteral nutrition appear to be less than previously reported, and represent a relatively small proportion of the total cost of care. This cost category analysis may have application in measuring and comparing parenteral nutrition service delivery in other institutions.

Care of the Child Assisted by Technology

Care of the Child Assisted by Technology

Netilmicin in the neonate: pharmacokinetic analysis and influence of parenteral nutrition

The aim of this study was to investigate the impact of parenteral nutrition on netilmicin pharmacokinetics in critically ill neonates during the first week of life. A total of 200 neonates (gestational ages 26.4-41 weeks) treated with netilmicin (4-5 mg/kg in extended dosing intervals) for postnatal sepsis in the first week of life received either fluid therapy or parenteral nutrition. Netilmicin peak and trough serum concentrations were monitored and netilmicin pharmacokinetic parameters were compared with and without parenteral nutrition. There were no statistically significant differences between the pharmacokinetic parameters of netilmicin (volume of distribution, elimination half-life, clearance) in critically ill neonates >32 weeks during the first week of life that received either fluid therapy or parenteral nutrition. For neonates <32 weeks this comparison was not feasible as the majority were parenterally fed. Provision of parenteral nutrition (versus fluid therapy) in critically ill neonates >32 weeks did not significantly affect netilmicin pharmacokinetics and therefore does not require modification of recommended netilmicin dosage regimens.

Physicochemical Stability of Parenteral Nutrition Supplied as All‐in‐One for Neonates

Common clinical practice for the provision of parenteral nutrition of neonates is to administer the nutrients in separate solutions. The aim of this study was to introduce and examine an alternative way of parenteral feeding for neonates, providing all-in-one parenteral regimes. Stability studies were carried out on 2 all-in-one admixtures. Stability assays consisted of the assessment of the admixture's (1) macroscopic aspect, (2) drop size measurement, (3) pH measurement, (4) peroxide value, and (5) alpha-tocopherol concentration. For the measurements, the admixtures were stored at 2 different temperatures, 4 degrees C (storage) and 25 degrees C (compounding), and then analyzed at a starting time, 24 hours, 48 hours, and 7 days after compounding. The 2 all-in-one parenteral admixtures for neonates were shown to be physically stable under analysis conditions, and there were no particles larger than 1 mum. The maximum loss of alpha-tocopherol was approximately 24%. In all-in-one admixtures, lipid peroxide occurred within 24 hours after the addition of the lipid emulsion. The addition of fat emulsion and fat-soluble vitamins did not alter the physical stability of parenteral admixtures for neonates. Moreover, the admixtures examined were relatively chemically stable for 24 hours, as far as vitamin E is concerned. Lipid peroxidation was the limiting factor for application stability of an all-in-one neonatal parenteral regimen.

A 15-year audit of home parenteral nutrition provision at the John Radcliffe Hospital, Oxford

Home parenteral nutrition (HPN) is an established option for patients suffering from intestinal failure, often pending definitive surgery, but sometimes for life or pending intestinal transplant. Care for patients with HPN is provided at centres other than designated intestinal failure units in the UK, but there are few data on outcomes. To audit the standard of care at one such centre using objective measures to compare with results published from other centres and intestinal failure units. 15-year retrospective audit of paper and computer-based records of all HPN patients (1990-2004). Demographic data, major line and metabolic complication rates and mortality were collected and analysed. 88 patients received HPN for a total period of 121 patient-years (median duration 217.8 days, range 18.3-3881.2, median age 40, range 3-73). Principal reasons for HPN were Crohns' disease (35.2%), mesenteric, infarction (11.4%), surgical complications (17.0%), intestinal motility disorder (10.7%). The frequency of major complications were line sepsis (0.35 episodes/patient-year), line occlusion (0.25 episodes/patient-year), subacute bacterial endocarditis (0.02 episodes/patient-year), cholestasis (0.17 episodes/patient-year) and central venous thrombosis (0.03 episodes/patient-year). Indications and complications were all within the range of published data. HPN can be delivered effectively outside designated intestinal failure units and the current data are representative of a standard of care.

Sustaining ELBW infants

Poindexter et al address important issues in the provision of parenteral nutrition to extremely low birth weight infants. Infants ∼26 weeks gestation and ∼800 grams birth weight who received “early” or “late” administration of hyperalimentation were compared. The “late” group followed conventional management at the time in the participating centers. The study was part of a larger study on provision of glutamine supplementation early in life on mortality and late-onset sepsis. Those outcomes did not differ. This secondary analysis is important because it allows comparison of the safety and the effect(s) of early hyperalimentation on somatic growth and neurodevelopmental outcome. The “early” group received hyperalimentation sooner and reached almost 3 gm/kg/day of parenteral amino acids by 4 days of age whereas the “late” group took twice as long to reach this level of “protein” intake. The infants in the “early” group had better indices of somatic growth at 36 weeks corrected age. However, these differences were not demonstrable by 18 months. There were no differences in standardized measures of neuromotor development. Nonetheless, these results are important for demonstrating that the provision of higher amounts of amino acids in hyperalimentation solutions earlier in life than conventionally practiced is safe and may afford significant benefits. Like many studies, this one raises more questions than it answers. Can higher doses of amino acids be given even earlier in life? If so, will growth effects be even more evident? Are there neurocognitive effects/benefits in other regimens, even though not demonstrated in these studies? With the improved survival of these smaller and at risk infants in nearly all units across the nation, these emerge as important questions to address in future investigations.

Intestinal Replacement Therapy: Timing and Indications for Referral of Patients to an Intestinal Rehabilitation and Transplant Program

Current treatment options for patients suffering from intestinal insufficiency include all forms of intestinal replacement therapy (IRT). Parenteral nutrition has achieved extended success for the majority of patients requiring interval treatment, however, complications leading to failure of this treatment increases with the duration of therapy. There is currently no consensus as to the appropriate timing for transplantation of the intestine or the timing of referral for evaluation at a center experienced with this therapy. Certain patient characteristics warrant evaluation. Those patients with no jejunoileum who have guaranteed lifelong parenteral dependence, both adult and pediatric, should be immediately referred to a transplant center due to the high likelihood of the development of liver disease. Patients with metastatic infectious complications from catheter sepsis, patients with cholestasis seen intermittently with sepsis episodes, patients who are not successfully weaning and who demonstrate progressive thrombocytopenia, and patients with motility disorder experiencing deterioration should also warrant early referral to an intestinal rehabilitation and transplant program. The objective of evaluation is to maximize the opportunities for rehabilitation while not missing the critical window of opportunity for successful transplantation when needed. We favor an aggressive directed approach to rehabilitation, coupled with psychological preparation for both transplantations and other options. Early referral requires trust between the patient, referring physician, and the transplant team to assure that a rush to judgment will not lead to a premature transplant. The current wait list mortality is high, mandating early referral and listing with an approach aimed at maximizing both the success of gastrointestinal support, as well as of transplantation when necessary.

Somatropin in short bowel syndrome: opening the door to trophic factor use

The management of short bowel syndrome is complex and frequently requires parenteral nutrition support to ensure the sufficient administration of nutrients and fluids. Despite advances in the provision of parenteral nutrition, this mode of nutritional support carries with it significant risks to the patient, impairs quality of life and is very costly. Since intestinal adaptation plays a key role in the successful management of patients with short bowel syndrome, recent investigations have focused on the use of trophic substances to enhance intestinal adaptation and increase the absorptive function of the remaining gut. Published reports from a number of studies conducted in animal models and humans with short bowel syndrome evaluating the efficacy of recombinant human growth hormone (i.e., somatropin) in this regard have demonstrated conflicting findings. However, substantial methodologic differences among the studies limit definitive conclusions regarding the benefit of this therapy on intestinal adaptat...

Intestinal rehabilitation and the short bowel syndrome: part 1.

The management of patients with intestinal failure due to short bowel syndrome (SBS) is complex, requiring a comprehensive approach that frequently necessitates long-term, if not life-long, use of parenteral nutrition (PN). Despite tremendous advances in the provision of PN over the past three decades, which have allowed significant improvements in the survival and quality of life of these patients, this mode of nutritional support carries with it significant risks to the patient, is very costly and, ultimately, does not attempt to improve the function of the remaining bowel. Intestinal rehabilitation refers to the process of restoring enteral autonomy and, thus, allowing freedom from parenteral nutrition, usually by means of dietary, medical, and, occasionally, surgical strategies. While recent investigations have focused on the use of trophic substances to increase the absorptive function of the remaining gut, whether intestinal rehabilitation occurs as a consequence of enhanced bowel adaptation or is simply a result of an optimized, comprehensive approach to the care of these patients remains unclear. In Part 1 of this review, an overview of SBS and pathophysiological considerations related to the remaining bowel anatomy in these patients will be provided. Additionally, a review of intestinal adaptation and factors that may enhance the adaptive process, focusing on evidence derived from animal studies, will also be discussed. In Part 2, relevant data on the development of intestinal adaptation in studies involving humans will be reviewed as will the general management of SBS. Lastly, the potential benefits of a multidisciplinary intestinal rehabilitation program in the care of these patients will also be discussed.

Education and training in nutrition support pharmacy practice

The contributions of nutrition support teams are well established in the United States.1–5 Pharmacists have been intimately involved since the inception of these teams, especially with the provision of parenteral nutrition.1,6 The first documentation of the pharmacist’s role on the nutrition support team was published nearly three decades ago.1 As technology advanced, nutrition support therapy became exceedingly more complex, and pharmacy nutrition support training became more formalized, the role of the pharmacist has continued to evolve into more diverse clinical roles.7–10 The University of Tennessee was among the first institutions in the country where a pharmacist was intimately involved in a clinical role on the nutrition support service. At first, the team was comprised of a physician and pharmacist, and only patients using parenteral nutrition were seen.1 They subsequently added a nurse and a dietitian to complete the multidisciplinary service. Due to the complexity of providing safe and effective metabolic support in patient care, the current role of the multidisciplinary members of the nutrition support team necessitates advanced education and training. There is some published information regarding educational efforts by dietitians11,12 and physicians13,14 for advanced nutrition support education and training, but data regarding specialized nutrition support education and training for pharmacists are lacking. This editorial highlights our approach at the University of Tennessee Health Science Center to provide an individual with the appropriate skills and knowledge to function as a clinical pharmacy practitioner, educator, and researcher. Elements of the education and training pathway, illustrated in Figure 1, are described in this report. Although it is our opinion that this figure reflects the optimal training pathways, the availability of specialized residencies and fellowships in pharmacy nutrition support unfortunately is limited. In a national survey of 166 individuals practicing in pharmacy nutrition support in 1990 and 1991, only 40% had a doctor of pharmacy degree, 35% had completed a general or pharmacy practice residency, and 16% completed a specialty residency or fellowship in nutrition support.15 With the adoption of a 6-y Doctor of Pharmacy program by all colleges of pharmacy and the continued growth of pharmacy practice residencies, these demographics have likely changed since that initial survey from over a decade ago.

Bacterial colonisation of midline and central venous catheters

The provision of parenteral nutrition conventionally requires the insertion of a central venous catheter (CVC) with the attendant risks of pneumothorax, vascular damage and line sepsis [1]. In addition, CVC insertion requires appropriately trained medical staff. It is possible to provide central venous access with peripherally inserted central catheters (PICC) but these are associated with malposition, catheter fracture, leakage and occlusion [2]. An alternative to these is the use of 20 cm single lumen 22 G venous catheters inserted in the antecubital fossa (midlines). This unit provides a 'midline' service for parental nutrition or long-term venous access, and this audit describes the experience of this service to date. All lines were inserted on a general ward by a trained theatre technician using standard sterile techniques including chlorhexidine or iodine (in 70% methylated spirit) skin preparation and a semipermeable film dressing (tegaderm™). At removal, midline tips were sent for microbiological analysis using a Maki roll technique. There were 160 midlines inserted over an 18 month period, 139 catheters were inserted for parental nutrition and 21 for other reasons. Catheters remained in situ for median of 6 days with a range of 1–60 days. Reasons for catheter removal included blockage (13%), concerns over arm swelling (17.5%) and completion of therapy (39%). Of the 160 midlines inserted, microbiological data were available on 120. There was an overall bacterial colonisation rate of 20.8%. By comparison the colonisation rate for CVC in this unit is 49%. The colonisation rates for midlines and CVCs become significantly different by day 7 (P = 0.03, χ2) and remain so thereafter. For midlines, the majority of catheters that eventually become colonised do so by day 8. In contrast, for CVCs the colonisation rate continues to rise until day 15. The majority of organisms isolated from midline catheters were staphylococcus epidermidis (19/27). Other organisms included β-haemolytic streptococcus (two cases), enterobacter aerogenese (two cases), MRSA (one case), coliform (one case), staphylococcus aureus (one case) and candida (one case). Midline catheters represent a simple technique that can be performed by nonmedical staff. They can be used for long-term intravenous access with a lower risk of colonisation than central venous catheters.

Prepubertal Growth in Children with Long-Term Parenteral Nutrition

In children who depend on long-term parenteral nutrition (PN), a major goal is to obtain optimal growth. The aim of this retrospective study was to analyze growth in children on long-term cyclic nocturnal home PN, over at least 8 years before puberty. Nine boys and 7 girls were studied. Their mean age at the time of study was 11 years with a mean PN duration of 10.5 (8.6–16.4) years. Diseases were short bowel syndrome (5), intractable diarrhea (4), chronic intestinal pseudo-obstruction (4) and long segment Hirschsprung’s disease (3). In each child, periods of at least 2 years were analyzed: either periods of regular growth (R: height gain >50th percentile), or slow growth (S: height gain ≤25th percentile). Results were expressed as mean ± SD. Comparisons were performed using either Student’s test for unpaired data or Wilcoxon’s test for paired data. PN provided a mean of 224 ± 80 mg nitrogen/kg/day and 43 ± 14 kcal/kg/day equivalent to 50% of recommended supplies. At the time of study, the population presented with weight (W) = –0.7 ± 0.8 SD and height (H) = –1.5 ± 1.3 SD. The difference between W and expected W for H (W/H) was significant (p < 0.002). W/H ratio was 105 ± 11%. For the total PN duration, weight gain was +0.2 ± 1.5 SD and height loss was –0.75 ± 1.4 SD. An excess weight gain occurred in parallel with the deflection of height gain. Of the 16 children, regular prepubertal growth was achieved in 4 only. The other 12 showed alternate periods of R and S. In 8 of them, 26.5 years of R and 33.5 years of S were compared, each child being his own control. PN nitrogen and energy supplies were significantly higher during R periods than during S periods. In the absence of any disease or treatment explaining the failure to thrive, inadequate PN supplies, especially in terms of nitrogen supply, are thought to be responsible for a negative nitrogen balance and slowed growth. In case of any deflection away from the individual growth curve, it is recommended to adjust the PN supply early, especially nitrogen supply.

Changes in parenteral nutrition supply when the nutrition support team controls prescribing

Changes in parenteral nutrition supply when the nutrition support team controls prescribing

Clinical Observations: Beyond the Prescription: Optimizing the Diet of Patients with Short Bowel Syndrome

The nutrition and metabolic problems of patients with short bowel syndrome (SBS) are complex. Although much effort has been devoted to optimizing the provision of parenteral nutrition to these patients, much less attention has been devoted to the role that an optimal enteral or oral diet might play in the management of these individuals. In addition to the role that luminal nutrition plays in bowel adaptation following resection, the provision of an appropriate diet prescription can influence absorption or stool or ostomy output. To optimize the effect of diet manipulation, the diet prescription must be translated into foods, and the foods into appropriate meals that recognize the variability that exists in this patient population. In addition to reviewing available literature, observations based upon our clinical experience caring for nearly 400 patients with SBS are presented.

Clinical Observations: National Advisory Group's Total Parenteral Nutrition (TPN) Guidelines: Why They Are Needed and Causes for Concern

In response to several incidents involving the improper preparation and administration of parenteral nutrition solutions, the American Society for Parenteral and Enteral Nutrition's (A.S.P.E.N.) Board of Directors charged the National Advisory Group to develop guidelines as standards of practice for the safe provision of parenteral nutrition; these guidelines were approved in January 1998. As with all practice guidelines, however, these recommendations are broad in scope and need to be interpreted by practitioners to fit the individual clinical scenario. A review of several cases illustrate that had the guidelines been in existence, potentially life‐threatening situations could have been avoided. More recent experiences are also reviewed in which the guidelines were applied, but crucial clinical issues that were not expressly addressed by the guidelines still resulted in opportunities for error. It is important to recognize that clinical guidelines for the safe provision of parenteral nutrition are effective in reducing some but not all sources of potential error.

Nutrition and Metabolic Support in Hematopoietic Stem Cell Transplantation: Where Do We Go From Here?

The use of hematopoietic stem cell transplantation (HSCT) has grown rapidly over the past decade because of improvement in cytoreductive regimens used before transplantation, immunosuppressive agents to prevent and treat graft-versus-host disease (GVHD), and the supportive care needed to bring patients through the rigors of prolonged pancytopenia. Many of these interventions used in HSCT lead to gastrointestinal symptoms including anorexia, nausea, vomiting, diarrhea, and abdominal pain. Nutrition and metabolic support often are needed for these patients when these symptoms are coupled with weight loss or hypercatabolism. In this issue of NCP, Dr Todd Mattox provides us with a superb review of the literature with information that we all need to know when caring for this challenging group of patients.' With an emphasis on the provision of parenteral nutrition (PN) in HSCT, Dr Mattox provides us with a thorough discussion of when and how to institute nutrition support and what nutrients to provide to maintain nitrogen, energy, and micronutrient balance. He also points out several of the controversial issues that surround nutrition support in HSCT. Pivotal questions that remain unanswered are who is the most appropriate candidate for PN and when should it be started? Recent literature suggests that patients who are given PN immediately after bone marrow transplant (BMT) are able to maintain their weight better than patients who receive IV fluids; however, this is at the expense of a greater incident of clinical infection and bacteremia.'