Standard Parenteral Nutrition Solutions Research Articles

Could Commercial Formulations Replace Individualized Prescription in Pediatric Home Parenteral Nutrition?

Standard parenteral nutrition (PN) solutions are safe and can meet the nutritional requirements of a significant number of pediatric patients. However, they may not always be adequate for those on long term PN. We aimed to compare the composition of individually tailored prescriptions in a pediatric population on home PN with that of available commercial PN formulations. Retrospective analysis of the individual prescriptions of metabolically stable pediatric patients on home PN over a 1-year period (March 2019 to March 2020). These were compared with commercially available solutions with electrolytes, and replacement was considered adequate if three successive criteria were met: non-protein calorie to volume ratio (maximum variation 15%); non-protein calorie to nitrogen ratio (NPC:N) (maximum variation either 20% for long term use or 35% for possible short term use); electrolyte concentration (maximum increase 20%). Twenty-four patients were included (67% male; median age 7.5 years). The most common diagnosis was short bowel syndrome (58%). Replacement with a standard formulation was considered appropriate for possible short term use (maximum variation of 35% in NPC:N) in 16 (67%) patients and for long term use (maximum variation of 20% in NPC:N), the number of patients decreased to 10 (42%). Standard PN solutions can be adequate for a significant proportion of pediatric patients on home PN. Their use in the short term may also be appropriate in holiday periods or in settings of limited resources or restricted access to hospital facilities, such as those imposed by the COVID-19 pandemic.

Clinical conditions and complications associated with parenteral nutrition use in critically ill patients admitted to an intensive care unit of a general hospital.

Objective: the aim of this study was to evaluate the clinical conditions, the existing complications, and the drug prescription profile of patients who received parenteral nutrition in the intensive care unit. Material and methods: this retrospective, analytical cohort study was carried out among individuals admitted to a public general hospital ICU. For data collection, the electronic medical records for the entire period of inpatient treatment were analyzed. Results: in total, 213 individuals who had received parenteral nutrition for a period greater than 48 hours were included in the study. Most participants were male and mean age was < 60 years; death occurred in 75 % of patients, and abdominal surgery was the main indication for parenteral nutrition. Hyperglycemia was the most common complication. The Mann-Whitney test showed that the individuals who died were using a higher number of medications. The increased use of medications correlated with use of PN and led to an increase in hospital length of stay and death rate (p-value < 0.001). There was a higher proportion of deaths among patients using standard parenteral nutrition solutions (76.9 %) as compared to the period when patients started receiving custom-made parenteral nutrition solutions (71.7 %). However, there was no statistical evidence of the association between type of nutrition and the outcome of death (p-value = 0.395). Conclusions: custom-made parenteral nutrition may result in benefits for the patients, such as a decrease in the number of medications used. The relationship between type of nutrition and the outcome of death did not prove to be statistically significant.

Production and stability study of a hospital parenteral nutrition solution for neonates

Standard parenteral nutrition solutions are mixtures comprising interacting components that may degrade themselves over time. The objective of this study was to investigate the physicochemical and microbiological stability of a hospital preparation for parenteral nutrition in neonatology. The analyses were performed throughout the storage of the preparations at 2–8 °C (up to 4 months). The extent of stability was based on the determination of amino acids dosage, visual and physicochemical properties (glucose and electrolytes concentrations, pH and osmolality measurements, particle counting) and microbiological analysis (sterility test). A thermal degradation of ascorbic acid was conducted to evaluate the antioxidant properties of the parenteral mixture. Physicochemical and microbiological controls were found to comply with the specifications. Amino acids showed a good stability throughout the 4months storage except for cysteine, which was progressively degraded to cystine, conferring a yellow coloration to parenteral solutions. Parenteral nutrition standards solutions remain stable for 4 months at 2–8 °C, ensuring safe administration in preterm infants.

Evaluation of the physicochemical compatibility of cyclosporin infusion and parenteral nutrition when intravenously administered via the same central line lumen

AbstractBackgroundPatients undergoing allogeneic haematopoietic stem cell transplantation require cyclosporin (CsA) infusion to be administered concurrently with parenteral nutrition (PN).AimsTo evaluate the physicochemical compatibility of parenteral CsA and PN administered via the same lumen of a central venous access device and to quantify and identify any particulate matter.MethodsThree PN formulations were tested. Standard PN solution and PN solution with glutamine manufactured by Baxter Healthcare and standard PN solution manufactured by Fresenius Kabi. CsA concentrate for intravenous infusion 250 mg/5 mL (Sandimmun, Novartis Pharmaceuticals) was used.PN solutions were mixed with CsA at different volume ratios to simulate different rates of co‐infusion in clinical practice.A real‐life simulation was also performed with CsA in glucose 5% co‐infused with the PN solution via the same lumen of a central venous access device.The size of colloidal species in the resulting samples was measured using dynamic light scattering.ResultsThe static experiments for all dilution ratios and types of PN with CsA indicated average particle diameters of less than 500 nm. Only one sample indicated a particle larger than 5 µm.The ‘real‐life’ simulation did not detect any particle with diameter greater than 5 µm. This was across all types of PN solutions and for all samples taken at a number of time points up to 24 h.ConclusionCommercially available PN formulations can be administered concurrently with CsA via the same lumen of a central venous access device. For infusions running up to 24 h, there is minimal risk of particle formation with a diameter greater than 5 µm.

Phase IV Prospective Clinical Study to Evaluate the Effect of Taurine on Liver Function in Postsurgical Adult Patients Requiring Parenteral Nutrition

Taurine's role in bile acid metabolism and anti-inflammatory activity could exert a protective effect on hepatobiliary complications associated with parenteral nutrition (PN). In this study, the effects of 2 amino acid solutions, with and without taurine, on liver function administered to nonacutely ill postsurgical patients as part of a short-term PN regimen were prospectively compared. Adult patients randomly received (double-blind) Tauramin 10% or a standard PN solution without taurine as the control (1.5 g amino acid/kg body weight [bw]/d; infusion rate of ≤4 mg glucose/kg bw/d) for a period of 5-30 days. γ-Glutamyl transpeptidase (GGT) and other indicators of liver function, glucose metabolism, lipid profile, inflammation markers, and treatment safety data were collected. Thirty-five patients receiving taurine PN and 39 receiving control PN were enrolled (intention-to-treat [ITT] population). Most patients (n = 62) discontinued after day 7 of follow-up (per-protocol [PP] population: n = 24 and n = 27, respectively). ITT patients with high GGT values after 5 days of PN comprised 68.6% and 64.1%, respectively. The mean change in GGT values with respect to the baseline values was 167 ± 192 and 157 ± 185 IU/L, respectively. Low-density lipoprotein (LDL) cholesterol levels after 7 days of PN were significantly decreased in the taurine PN group of PP patients (-2.83 ± 30.9 vs 23.9 ± 27.0 mg/dL for control PN; P < .05). None of the adverse events reported (taurine PN: n = 6; control PN: n = 7) were treatment related. PN solutions with and without taurine had similar effects on liver function parameters, except for an LDL reduction in PN with taurine, when administered to nonacutely ill postsurgical patients in the short term (5-7 days).

Aluminium exposure from parenteral nutrition in preterm infants and later health outcomes during childhood and adolescence

Aluminium is the most common metallic element, but has no known biological role. It accumulates in the body when protective gastrointestinal mechanisms are bypassed, renal function is impaired, or exposure is high - all of which apply frequently to preterm infants. Recognised clinical manifestations of aluminium toxicity include dementia, anaemia and bone disease. Parenteral nutrition (PN) solutions are liable to contamination with aluminium, particularly from acidic solutions in glass vials, notably calcium gluconate. When fed parenterally, infants retain >75% of the aluminium, with high serum, urine and tissue levels. Later health effects of neonatal intravenous aluminium exposure were investigated in a randomised trial comparing standard PN solutions with solutions specially sourced for low aluminium content. Preterm infants exposed for >10 d to standard solutions had impaired neurologic development at 18 months. At 13-15 years, subjects randomised to standard PN had lower lumbar spine bone mass; and, in non-randomised analyses, those with neonatal aluminium intake above the median had lower hip bone mass. Given the sizeable number of infants undergoing intensive care and still exposed to aluminium via PN, these findings have contemporary relevance. Until recently, little progress had been made on reducing aluminium exposure, and meeting Food and Drug Administration recommendations (<5 μg/kg per d) has been impossible in patients <50 kg using available products. Recent advice from the UK Medicines and Healthcare regulatory Authority that calcium gluconate in small volume glass containers should not be used for repeated treatment in children <18 years, including preparation of PN, is an important step towards addressing this problem.

Influence of Adding Pyrroloquinoline Quinone to Parenteral Nutrition on Gut‐Associated Lymphoid Tissue

Experimental intravenous (IV) parenteral nutrition (PN) diminishes gut-associated lymphoid tissue (GALT) cell number and function. PN solution cannot maintain GALT at the same level as a normal diet, even when delivered intragastrically (IG). Previous studies demonstrated pyrroloquinoline quinone (PQQ)-deficient mice to be less immunologically responsive. Because standard (STD) PN solution lacks PQQ, PQQ supplementation may prevent PN-induced GALT changes. This study was designed to determine the influence of adding PQQ to PN on GALT. In experiment 1, mice (n = 32) were randomized to chow, IV-STD-PN, and IV-PQQ-PN groups. The chow group was fed chow with the same caloric content as PN. The IV-STD-PN group received STD-PN solution, whereas the IV-PQQ-PN group was given PQQ (3 mcg/d)-enriched PN by the IV route. After 5 days of feeding, lymphocytes were isolated from the Peyer's patch (PPs), intraepithelial space (IE), and lamina propria (LP) of the small intestine. GALT lymphocyte number and phenotype (αβTCR+, γδTCR+, CD4+, CD8+, B220+ cells) and intestinal immunoglobulin A (IgA) level were determined. In experiment 2, mice (n = 28) were randomized to IG-STD-PN or IG-PQQ-PN group. After IG nutrition supports, GALT mass and function were determined as in experiment 1. The IV-PQQ-PN group showed increased PP lymphocyte number and PP CD8+ cell number compared with the IV-STD PN group. The IG-PQQ-PN group had significantly greater PP lymphocyte number and PP CD4+ cell numbers than the IG-STD-PN group. Neither IV nor IG PQQ treatment raised IgA level. PQQ added to PN partly restores GALT mass, although its effects on GALT function remain unclear.

Assessment of standard parenteral nutrition in children

Nowadays, there is a stronger consensus on the proceedings of nutritional support with parenteral nutrition (PN) in paediatrics, the prescription standards, its formulation, elaboration, and nutritional requirements in order to improve the process quality and the patient's safety. The use of standardized PN solutions in children is rare due to the difficulty to adapt them to every pathophysiologic condition. In order to do so, in 2006 we designed and validated a big range of standard solutions for children weighing more than 10 kg or being older than 1 year. To assess the use of standard PN solutions and their suitability in children from January of 2006 until June of 2008: the frequency of prescription of standard solutions by age, weight, and indication, as well as their modifications. We compared the nutrients given by individualized PN solutions versus the recommendations of the Reference Guidelines and standardised PN. 47 children with a mean weight of 26.6 kg (9-50) and mean age 6.8 years (1-14) received 539 units of PN. Standardized PN (437) were used in 83% of the patients. Their total energy requirements were reached within 1-3 days by using one to three types of formulas. Only 4% (22) of them were modified, with easily feasible changes: volume increase (16), glucose lowering (3), and potassium increase (3). The analysis of the individualized PN in 8 children shows the same trend, with a caloric intake lower than 33% of the recommended one. Standardized PN meet the nutritional requirements in most of the patients according to their morbid condition, highlighting their adaptability and versatility. Their use has eased the prescription-validation-preparation circuit and has improved the efficiency of the process.

Aluminum Exposure From Parenteral Nutrition in Preterm Infants: Bone Health at 15-Year Follow-up

Aluminum has known neurotoxicity and may impair short-term bone health. In a randomized trial, we showed reduced neurodevelopmental scores in preterm infants who were 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. Bone area (BA) and bone mineral content (BMC) of lumbar spine, hip, and whole body were measured with dual radiograph absorptiometry in 13- to 15-year-olds who were born preterm and randomly assigned standard or aluminum-depleted parenteral nutrition solutions during the neonatal period. Fifty-nine children (32% of survivors) were followed. Those who were randomly assigned to standard parenteral nutrition solution had lower lumbar spine BMC, apparently explained by a concomitant decrease in bone size. In nonrandomized analyses, children who were exposed to neonatal aluminum intakes above the median (55 microg/kg) had lower hip BMC (by 7.6% [95% confidence interval: 0.12-13.8]; P = 0.02), [corrected] independent of bone (or body) size. Neonates who are 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 individuals and the sizeable number of contemporary infants who undergo intensive neonatal care and are still exposed to aluminum via parenteral feeding solutions, the potential adverse long-term consequences of early aluminum exposure now deserve renewed attention.

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.

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.

Interleukin‐7 Dose‐Dependently Restores Parenteral Nutrition–Induced Gut‐Associated Lymphoid Tissue Cell Loss but Does Not Improve Intestinal Immunoglobulin A Levels

Without enteral nutrition, the mass and function of gut-associated lymphoid tissue (GALT), a center of systemic mucosal immunity, are reduced. Therefore, new therapeutic methods, designed to preserve mucosal immunity during parenteral nutrition (PN), are needed. Our recent study revealed that exogenous interleukin-7 (IL-7; 1 microg/kg twice a day) restores the GALT cell mass lost during intravenous (IV) PN but does not improve secretory immunoglobulin A (IgA) levels. Herein, we studied the IL-7 dose response to determine the optimal IL-7 dose for recovery of GALT mass and function during IV PN. We hypothesized that a high dose of IL-7 would increase intestinal IgA levels, as well as GALT cell numbers. Male mice (n = 42) were randomized to chow, IL-7-0, IL-7-0.1, IL-7-0.33, IL-7-1 and IL-7-3.3 groups and underwent jugular vein catheter insertion. The IL-7 groups were fed a standard PN solution and received IV injections of normal saline (IL-7-0), 0.1, 0.33, 1, or 3.3 microg/kg of IL-7 twice a day. The chow group was fed chow ad libitum. After 5 days of treatment, the entire small intestine was harvested and lymphocytes were isolated from Peyer's patches (PPs), intraepithelial (IE) spaces, and the lamina propria (LP). The lymphocytes were counted and phenotypes determined by flow cytometry (alphabetaTCR, gammadeltaTCR, CD4, CD8, B cell). IgA levels of small intestinal washings were also examined using ELISA (enzyme-linked immunoabsorbent assay). IL-7 dose-dependently increased total lymphocyte numbers in PPs and the LP. The number of lymphocytes harvested from IE spaces reached a plateau at 1 microg/kg of IL-7. There were no significant differences in any phenotype percentages at any GALT sites among the groups. IgA levels of intestinal washings were significantly higher in the chow group than in any of the IL-7 groups, with similar levels in all IL-7 groups. Exogenous IL-7 dose-dependently reverses PN-induced GALT cell loss, with no major changes in small intestinal IgA levels. IL-7 treatment during PN appears to have beneficial effects on gut immunity, but other therapeutic methods are needed to restore secretory IgA levels.

Determinants of Insulin Availability in Parenteral Nutrition Solutions

Management of hyperglycemia in patients receiving parenteral nutrition (PN) often includes the addition of regular insulin to the PN solution. A literature review has shown insulin availability in such solutions to range from 10% to 95%. This discrepancy in availability may be due to differences in the composition of the PN solution, the final concentration of insulin, or the assay method used to determine insulin concentrations. The purpose of this study was to evaluate insulin recovery from a standard PN solution used at our medical center. Solutions were manually prepared in our pharmacy according to standard practice. Multivitamins and trace elements were added to 1 of 2 L of solution each day. Each of 3 simulated patients received 2 L of solution per day for 3 consecutive days. Samples from each bottle were drawn at baseline, 1 hour after the start of infusion, and 1 hour before the end of infusion and were subsequently analyzed for immunoreactive insulin levels by radioimmunoassay. Recovery of insulin from solutions containing multivitamins and trace elements was much greater (95%) than from those without (5%). The presence of multivitamins and trace elements is a major determinant of insulin availability in PN solutions. Additional research is necessary to determine the mechanism mediating this effect and to assess its clinical significance.

Parenteral nutrition with standard solutions in paediatric intensive care patients

Paediatric intensive care patients often require parenteral nutrition (PN). Only very few standard mixtures are available for infants and children. Individual PN solutions need to be compounded manually on the ward, if preparation by the hospital pharmacy is not feasible. Since manual compounding is associated with a greater risk of compounding errors and microbial contamination, the use of standard solutions might be a preferable alternative. We evaluated the use of standard solutions on the paediatric intensive care unit of the von Hauner Children's Hospital at the University of Munich over a period of 8 months. PN solutions were either prescribed individually or as standard solutions. We evaluated the frequency of standard solution prescriptions and their modification, compared nutrient intakes with standard vs. individual PN solutions as well as the occurrence of laboratory anomalies. Standard PN solutions were prescribed in 68% of cases, individual PN solutions in 32%. Modifications of standard PN solutions were performed in 54%. The intake of a number of macronutrients and electrolytes was similar with individual and standard PN, but calcium and phosphate intakes were lower with individual total PN. Electrolyte imbalances occurred slightly more often with individual PN than with standard PN (34% vs. 26%, respectively). Standard PN solutions were used in the majority of patients on a paediatric intensive care unit. We did not detect indications for inadequacy of standard solutions in the majority of patients reviewed.

The use of standard parenteral nutrition solutions in pediatrics: A UK perspective

The use of standard parenteral nutrition solutions in pediatrics: A UK perspective

Nucleotides and intestine.

Dietary nucleotides play an important role in the growth and development of the intestine. Parenteral supplementation of nucleic acids may be necessary to maintain the mucosal proliferation and barrier functions during parenteral nutrition (PN). Male Wistar rats were divided into 3 groups: FED (food ad libitum with saline infusion); PN (a standard PN solution); and OG (OG-6, a mixture of nucleotide and nucleosides, in addition to the PN solution). The mucosal wet weight, protein, and DNA contents, villous height and crypt depth, electronmicroscopic examination of the intercellular junctions, proliferating activity of the mucosal cells, mucosal permeability, bacterial translocation, and mucosal cathepsin activities were examined. The wet weight, protein, and DNA contents of the jejunal mucosa were significantly increased in the OG group, compared with those in the PN group. The morphometric examination revealed a significant increase in the villous height but not in the crypt depth in the OG group. The widths of both the tight and intermediate junctions were narrower in the OG group than those in the PN group. The activity of diamine oxidase was increased in the OG group, compared with that in the PN group. The ratio of proliferating cell nuclear antigen positive cells and the index of bromodeoxy uridine labeling index in the OG group were as high as in the FED group, and significantly higher than those in the PN group. The portal concentration of fluorescein isothiocyanate-dextran 70,000 after intragastric loading was significantly higher in the PN group than that in OG group. Likewise, the rate of urinary lactulose excretion after intragastric loading was higher in the PN group. The positive rate of bacteria cultured in mesenteric lymph nodes was higher in the PN group than in the OG group although the difference was not significant. The activities of mucosal cathepsins (B, H, and L), markers for phagocytic degradation of extrinsic substances and organisms, were higher in the PN group than those in the OG and FED groups. Parenteral supplementation of nucleic acids supports the mucosal cell proliferation and functions.

Development of pediatric and neonatal parenteral nutrition order forms.

The diversity of nutritional needs within the pediatric population makes ordering parenteral nutrition (PN) for infants and children a difficult task for inexperienced clinicians. A well designed PN order form can simplify this task. Standard PN solutions, tables with age-specific nutrient requirements, and guidelines for advancing substrate may improve PN prescriptions and serve as an educational tool. The development of an optimal PN order form for an institution requires consideration of many factors, including the patient population, requirements of the institution, and the needs of the staff and students. One nutrition support team's experience in developing pediatric PN order forms is described.

Effect of parenteral calcium and phosphorus therapy on mineral retention and bone mineral content in very low birth weight infants

If calcium and phosphorus are administered to very low birth weight infants in amounts larger than those currently used in standard parenteral nutrition solutions, apparent retention of calcium and phosphorus (intake minus urinary excretion) will increase and bone mineralization will improve. Randomized, controlled, double-blind trial. Neonatal intensive care unit. Twenty-four very low birth weight infants (< 1.2 kg) expected to receive parenteral nutrition exclusively for approximately 3 weeks beginning 3 days after birth. Infants received parenteral nutrition solutions, either the standard mixture containing 1.25 mmol calcium and 1.5 mmol phosphorus per deciliter (group STAND: n = 12, birth weight 921 +/- 171 gm, gestational age 27 +/- 2 weeks (mean +/- SD)) or 1.7 mmol calcium and 2.0 mmol phosphorus per deciliter (group HIGH: n = 12, 857 +/- 180 gm, 27 +/- 2 weeks). Intake, urinary excretion, and apparent retention of calcium, phosphorus, and magnesium every 3 days during parenteral nutrition therapy. Serum indexes of mineral status twice during therapy. Bone mineral content of the distal segment of the left radius at 1, 4, 8, and 26 weeks. Apparent calcium retention (1.2 +/- 0.2 vs 1.6 +/- 0.2 mmol.kg-1.d-1) and phosphorus retention (1.4 +/- 0.2 vs 1.8 +/- 0.4 mmol.kg-1.d-1) differed significantly (p < 0.01) between groups STAND and HIGH, respectively; neither changed with the duration of parenteral nutrition therapy. Serum calcium, magnesium, parathyroid hormone, 25-hydroxyvitamin D, and osteocalcin concentrations were similar in both groups. Serum phosphorus concentration was significantly higher in group HIGH than in group STAND (p = 0.025). The absolute bone mineral content and the rate of increase in bone mineral content between 1 and 4, 1 and 8, and 1 and 26 weeks were significantly greater in group HIGH than in group STAND. Increased parenteral intakes of calcium and phosphorus resulted in greater retention of these minerals during parenteral nutrition therapy and in greater bone mineral content after therapy.

Invited Review: Infection Control of Parenteral Nutrition Solutions

Microbial contamination of parenteral nutrition solutions is a preventable cause of in patients receiving nutrition support. The components of the parenteral nutrition solutions have variable microbial growth potential. Crystalline amino acid and dextrose solutions are poor growth media for bacteria but may support fungal growth. Lipid emulsions provide an excellent medium for growth of bacteria and fungal species. Total nutrient admixtures will support microbial growth better than standard parenteral nutrition solutions will but less well than will lipid emulsion alone. Control of infection related to contaminated infusate depends on compounding procedure, quality control, appropriate storage, and procedures to prevent in-use contamination. Guidelines are presented for the preparation and administration of parenteral nutrition infusates that will minimize microbial contamination.

Prospective randomized double‐blind trial of branched chain amino acid enriched versus standard parenteral nutrition solutions in traumatized and septic patients

The addition of branched chain amino acids (BCAA) to total parenteral nutrition (TPN) solutions of balanced aminoacid composition has been reported to result in improved nitrogen balance, preservation of plasma protein levels, and improved immune function; however, only a few large clinical studies have been performed, yielding conflicting results. We, therefore, studied in a prospective, randomized double blind trial, the effects of BCAA enrichment of an otherwise isonitrogenous and isocaloric TPN solution on plasma protein levels in 101 traumatized and septic patients. TPN-derived nitrogen intake was similar in both study groups. Nitrogen balances in the BCAA group (n = 49) were not different from those in the standard group (n = 52). Plasma total protein levels increased significantly in the standard group resulting in a significant difference between study groups on day 7. Pre-albumin levels increased significantly in the BCAA group and in the standard group. The number of neutrophils (rods) was significantly lower in the standard group compared to the BCAA group on day 7. Lymphocytes increased significantly in the standard group as did the number of platelets, resulting in a significant difference between study groups on day 7. We conclude that BCAA enrichment of standard TPN solutions does not result in more efficient nitrogen metabolism in septic or traumatized patients.