Total Parenteral Nutrition Solutions Research Articles

Evidence and Perspectives for Choline Supplementation during Parenteral Nutrition-A Narrative Review.

Choline is an essential nutrient, with high requirements during fetal and postnatal growth. Tissue concentrations of total choline are tightly regulated, requiring an increase in its pool size proportional to growth. Phosphatidylcholine and sphingomyelin, containing a choline headgroup, are constitutive membrane phospholipids, accounting for >85% of total choline, indicating that choline requirements are particularly high during growth. Daily phosphatidylcholine secretion via bile for lipid digestion and very low-density lipoproteins for plasma transport of arachidonic and docosahexaenoic acid to other organs exceed 50% of its hepatic pool. Moreover, phosphatidylcholine is required for converting pro-apoptotic ceramides to sphingomyelin, while choline is the source of betaine as a methyl donor for creatine synthesis, DNA methylation/repair and kidney function. Interrupted choline supply, as during current total parenteral nutrition (TPN), causes a rapid drop in plasma choline concentration and accumulating deficit. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) defined choline as critical to all infants requiring TPN, claiming its inclusion in parenteral feeding regimes. We performed a systematic literature search in Pubmed with the terms "choline" and "parenteral nutrition", resulting in 47 relevant publications. Their results, together with cross-references, are discussed. While studies on parenteral choline administration in neonates and older children are lacking, preclinical and observational studies, as well as small randomized controlled trials in adults, suggest choline deficiency as a major contributor to acute and chronic TPN-associated liver disease, and the safety and efficacy of parenteral choline administration for its prevention. Hence, we call for choline formulations suitable to be added to TPN solutions and clinical trials to study their efficacy, particularly in growing children including preterm infants.

False-positive results of galactomannan assays in patients administered glucose-containing solutions

Galactomannan (GM) is a polysaccharide cell wall component released by Aspergillus spp., and an immunoenzymatic GM assay is used for the diagnosis of invasive pulmonary aspergillosis. We evaluated the cause of strong positivity for GM in patients with no typical signs of aspergillosis. Repeat assays were performed using different instruments and reagent lots, but there were no differences in results among the assays. Patients with strongly positive GM results were investigated. Medication histories revealed that 14 of 23 patients had been administered total parenteral nutrition solution from one manufacturer and 4 patients had been administered dextrose solution from a different manufacturer before being tested. The results of GM assays conducted on samples of dextrose solution and the glucose fraction of the total parenteral nutrition solution were strongly positive, confirming the causes of the false-positive reactions. We hypothesize that a trace amount of GM was introduced into the glucose-containing solutions because glucoamylase, which is necessary for the saccharification step of glucose synthesis, was derived from Aspergillus niger. To enhance patient care and prevent unnecessary antifungal prescriptions, healthcare providers and manufacturers of healthcare products need to be aware of the possibility of false-positive reactions for GM.

Exposure of preterm neonates to toxic metals during their stay in the Neonatal Intensive Care Unit and its impact on neurodevelopment at 2 months of age

BackgroundPremature neonates might be exposed to toxic metals during their stay in the neonatal intensive care unit (NICU), which could adversely affect neurodevelopment; however, limited evidence is available. The present study was therefore designed to assess the exposure to mercury, lead, cadmium, arsenic, and manganese of preterm neonates who received total parenteral nutrition (TPN) and/or red blood cell (RBC) transfusions during their NICU stay and the risk of neurodevelopment delay at the age of 2 months. MethodsWe recruited 33 preterm neonates who required TPN during their NICU admission. Blood samples were collected for metal analysis at two different time points (admission and before discharge). Metals in the daily TPN received by preterm neonates were analyzed. Neurodevelopment was assessed using the Ages and Stages Questionnaire Edition 3 (ASQ-3). ResultsAll samples of TPN had metal contamination: 96% exceeded the critical arsenic limit (0.3 μg/kg body weight/day); daily manganese intake from TPN for preterm neonates exceeded the recommended dose (1 µg/kg body weight) as it was added intentionally to TPN solutions, raising potential safety concerns. All samples of RBC transfusions exceeded the estimated intravenous reference dose for lead (0.19 µg/kg body weight). Levels of mercury, lead and manganese in preterm neonates at discharge decreased 0.867 µg/L (95% CI, 0.76, 0.988), 0.831 (95%CI, 0.779, 0.886) and 0.847 µg/L (95% CI, 0.775, 0.926), respectively. A decrease in ASQ-3-problem solving scores was associated with higher levels of blood lead in preterm neonates taken at admission (ß = −0.405, 95%CI = −0.655, −0.014), and with plasma manganese (ß = −0.562, 95%CI = −0.995, −0.172). We also observed an association between decreased personal social domain scores with higher blood lead levels of preterm neonates before discharge (ß = −0.537, 95%CI = −0.905, −0.045). ConclusionOur findings provide evidence to suggest negative impacts on the neurodevelopment at 2 months of preterm infants exposed to certain metals, possibly related to TPN intake and/or blood transfusions received during their NICU stay. Preterm neonates may be exposed to levels of metals in utero.

Effects of Fish Oil (SMOFlipid®) and Olive Oil Lipid (ClinOleic®) on Neonatal Morbidities in Preterm Infants.

Objective:Total parenteral nutrition (TPN) is very important for providing optimal nutrition during the critical developmental period of preterm newborns. Thus, there is a need to optimize TPN solutions to reduce morbidities. This study aimed to examine the effects of olive oil (ClinOleic®) and fish oil (SMOFlipid®) therapies on the frequencies of neonatal morbidities.Methods:Premature newborns hospitalized in the neonatal intensive care unit and receiving TPN for at least 14 days were included in the study. Newborns who were hospitalized and received olive oil-based lipid (ClinOleic®) were included in the olive oil group, and those who received omega-3 containing multi-lipid (SMOFlipid®) were included in the SMOFlipid group.Results:This study enrolled a total of 222 very-low-birth-weight premature newborns. The breastfeeding rate in the olive oil group was significantly lower than that in the SMOFlipid group (p<0.05). The rate of necrotizing entercolitis (NEC) in the olive oil group was significantly higher than that in the SMOFlipid group (p<0.05). The rate of bronchopulmonary dysplasia (BPD) in the SMOFlipid group was lower than that in the olive oil group (p<0.05).Conclusions:The rates of BPD and NEC were lower in the fish oil group. In this situation, fish oil therapy may provide protection against the development of BPD and NEC. Prospective studies are needed to determine whether this is caused by lipid therapy or an effect of breast milk.

Venous Thrombosis of the Mammary Vein Following Peripherally Inserted Central Catheter for Total Parenteral Nutrition Relying on Ecg Tip Confirmation Technology

Total parenteral nutrition (TPN) is a life-saving therapy for patients who are not able to utilize the gastrointestinal tract. There are several different types of central venous catheters (CVC) used to deliver TPN. To safely deliver hyperosmotic TPN solutions, CVC tip position should be in the in lower superior vena cava (SVC) or at the junction of SVC and right atrium (RA). New techniques such as intravascular electrocardiogram (ECG) are being used for tip confirmation to help facilitate expedient use of PICC lines replacing the need for chest x-ray (CXR) confirmation. We present a case of a TPN patient who had a PICC line placed, and ECG confirmed tip as being in the SVC. The patient developed chest pain with flushing of the PICC prompting surgical service to obtain a CXR. The CXR suggested the line was in the either in mammary vein or aorta and recommended replacement. Interventional radiology flushed a small amount of contrast through the PICC and fluoroscopy confirmed the PICC tip was in the left internal mammary vein with reflux of contrast in the left innominate vein. The left innominate vein was occluded due to thrombosis and vasospasm. The patient required increased level of care (PCU) for 2 days, but was eventually discharged with home total parenteral nutrition and has done well. We conclude that care should be taken when using ECG confirmation for PICC tip placement and we feel that patients requiring hyperosmotic TPN should still require CXR confirmation to ensure tip appropriate tip location.

The Perimetric Protuberance-Periosteal Chondroma

Total parenteral nutrition (TPN) is a life-saving therapy for patients who are not able to utilize the gastrointestinal tract. There are several different types of central venous catheters (CVC) used to deliver TPN. To safely deliver hyperosmotic TPN solutions, CVC tip position should be in the in lower superior vena cava (SVC) or at the junction of SVC and right atrium (RA). New techniques such as intravascular electrocardiogram (ECG) are being used for tip confirmation to help facilitate expedient use of PICC lines replacing the need for chest x-ray (CXR) confirmation. We present a case of a TPN patient who had a PICC line placed, and ECG confirmed tip as being in the SVC. The patient developed chest pain with flushing of the PICC prompting surgical service to obtain a CXR. The CXR suggested the line was in the either in mammary vein or aorta and recommended replacement. Interventional radiology flushed a small amount of contrast through the PICC and fluoroscopy confirmed the PICC tip was in the left internal mammary vein with reflux of contrast in the left innominate vein. The left innominate vein was occluded due to thrombosis and vasospasm. The patient required increased level of care (PCU) for 2 days, but was eventually discharged with home total parenteral nutrition and has done well. We conclude that care should be taken when using ECG confirmation for PICC tip placement and we feel that patients requiring hyperosmotic TPN should still require CXR confirmation to ensure tip appropriate tip location

Stability of Six Drugs in Total Parenteral Nutrition Solution

Elneopa NF No. 1 and No. 2 infusions are total parenteral nutrition solutions packaged in four-chambered infusion bags. They have been used as home parenteral nutrition, with various drugs injected into the infusion bags, for treating patient symptoms. In this study, we investigated the stability of six drugs, including famotidine, scopolamine butylbromide, furosemide, bromhexine hydrochloride, betamethasone sodium phosphate, and metoclopramide hydrochloride in the infusion bags under dark conditions at 4℃ for 7 days. Additionally, we developed a high-performance liquid chromatography method to determine drug concentrations in the infusions. The concentrations of injected famotidine, scopolamine butylbromide, and betamethasone sodium phosphate remained unchanged when the four chambers of Elneopa NF No. 1 and No. 2 were opened and the infusions were mixed. Their respective concentrations in the upper and lower chambers also remained unchanged. The concentration of furosemide in the upper chamber of the No. 1 infusion bag decreased after 5 days, although no change was observed in the other chambers and the mixed infusions with the four chambers opened. The concentration of bromhexine hydrochloride slightly decreased in the upper chambers (approximately 3%) after the co-infusion but decreased significantly in the other chambers and the mixed infusions with the four chambers opened. The concentration of metoclopramide hydrochloride significantly decreased in the upper chambers after the co-infusion; however, no change in concentration was observed in the other chambers and the mixed infusion with the four chambers opened. The results of this study provide useful information on home-based parenteral nutrition.

How to perform appropriate flushing after lipid emulsion administration using totally implantable venous access devices in long-term total parenteral nutrition and home parenteral nutrition.

There has been no clear evidence regarding the appropriate method of flushing catheters and totally implantable venous access devices (TIVADs) after lipid emulsion (LE) administration. Therefore, the aim of the study was to identify appropriate methods of flushing to minimize residual LE when using TIVADs to ensure the safety of long-term total parenteral nutrition (TPN) and home parenteral nutrition (HPN). A soybean oil LE containing indocyanine green (ICG) was administered from the injection site of the primary infusion set for flowing TPN, and LE dynamics were evaluated by a fluorescence imaging system. TIVADs were connected to the end of the infusion sets. After LE administration, the tubes and chambers were flushed from the injection site using saline at various speeds (20, 40, 60mL/min), with and without pulsation. The washout effect of TPN solution after LE administration followed by flushing was examined, as was the washout effect of size differences in the infusion sets. When the LE was flushed with 20mL of saline immediately after administering the LE using a standard infusion set (inner diameter 2.5mm), the LE still remained in the tubes and chambers under any flushing condition. Flushing the LE from the injection site with 10mL of saline and then flowing >240mL of TPN solution were effective for minimizing residual LE inside the tubes and chambers. When using an infusion set with a small inner diameter (1.0mm), the LE inside the tubes and chambers was almost discharged with ≥20mL of saline immediately after administering the LE. In all settings, flushing with/without pulsation did not affect LE washout efficacy. Flushing immediately with saline ≥10mL and then flowing >240mL of primary PN solution after soybean oil LE administration using the standard infusion set or flushing with 20mL saline immediately after administering the soybean oil LE using the infusion set with a small inner diameter are effective for minimizing the residual LE in the catheter and TIVAD, ensuring the safety of long-term TPN and HPN.

The Impact of Glucose-Based or Lipid-Based Total Parenteral Nutrition on the Free Fatty Acids Profile in Critically Ill Patients.

Introduction: Our study aim was to assess how the macronutrient intake during total parenteral nutrition (TPN) modulates plasma total free fatty acids (FFAs) levels and individual fatty acids in critically ill patients. Method: Adult patients aged 18–80, admitted to the intensive care unit (ICU), who were indicated for TPN, with an expected duration of more than three days, were included in the study. Isoenergetic and isonitrogenous TPN solutions were given with a major non-protein energy source, which was glucose (group G) or glucose and lipid emulsions (Smof lipid; group L). Blood samples were collected on days 0, 1, 3, 6, 9, 14, and 28. Results: A significant decrease (p < 0.001) in total FFAs occurred in both groups with a bigger decrease in group G (p < 0.001) from day 0 (0.41 ± 0.19 mmol∙L−1) to day 28 (0.10 ± 0.07 mmol∙L−1). Increased palmitooleic acid and decreased linoleic and docosahexaenoic acids, with a trend of increased mead acid to arachidonic acid ratio, on day 28 were observed in group G in comparison with group L. Group G had an insignificant increase in leptin with no differences in the concentrations of vitamin E, triacylglycerides, and plasminogen activator inhibitor-1. Conclusion: Decreased plasma FFA in critically ill patients who receive TPN may result from increased insulin sensitivity with a better effect in group G, owing to higher insulin and glucose dosing and no lipid emulsions. It is advisable to include a lipid emulsion at the latest from three weeks of TPN to prevent essential fatty acid deficiency.

Stability of Insulin in Total Parenteral Nutrition Solutions

Elneopa NF No. 1 and No. 2 infusions are complete parenteral nutrition solutions packaged as four-chambered bags. They have been used for home parenteral nutrition, with insulin injected into the bags for patients whose blood glucose becomes elevated. In this study, the stability of insulin in No. 1 and No. 2 bags was investigated. The quantity of insulin in Elneopa NF No. 2 was significantly lower than that in Elneopa NF No. 1. When insulin was injected into the upper chamber of either product, decreases in insulin levels were not observed. In contrast, the levels of insulin injected into the lower chamber of both products significantly decreased, with a larger difference in Elneopa NF No. 2. As the amino acid content is different between No. 1 and No. 2, amino acids may be considered a potential cause for the degradation of insulin in the bags. In addition, decreases in insulin levels were observed as the solutions passed through infusion sets just after flushing began, with both Elneopa NF No. 1 and No. 2. In conclusion, the concentration of insulin injected into the Elneopa infusion bags decreases, especially in No. 2 bags, and insulin is absorbed by the infusion sets.

Modified Rat-Tail-Fixed Model of Parenteral Nutrition to Study Liver Injury

For patients with intestinal failure, parenteral nutrition (PN) is a life-saving therapy. Unfortunately, PN does have serious adverse effects. The purpose of our study was to establish a tail-fixed and reproducible animal model of PNALD in which to explore the pathogenesis and evaluate various potential therapeutic manipulations as potential methods of treatment or prevention. Forty SD rats were randomly assigned to parenteral nutrition group or control group. A central venous catheter was inserted for intravenous infusion of a total parenteral nutrition solution (TPN group) or saline (control group) for 1 week or 2 weeks. Survival rate, hepatic biochemical tests, and liver pathology were analyzed. There was no significant difference in survival rate between the two groups at 1 and 2 weeks. The TPN group showed significant increases in direct bilirubin, total bilirubin, and serum aminotransferase than the control group (P < 0.05). Livers in the TPN group had severe, diffuse involvement of hepatocytes by macrovesicular and microvesicular steatosis. The pathological scores were significantly higher in the TPN group than the control group (P < 0.05). The model provides the opportunity to further investigate pathogenesis and treatment of parenteral nutrition–associated liver disease.

Physicochemical Compatibility of Amiodarone with Parenteral Nutrition.

Y-site administration of total parenteral nutrition (TPN) and drugs is frequently required in the intensive care setting. Amiodarone is commonly administered by continuous intravenous infusion and subject to be co-administered via a Y-site with TPN. The aim of this study is to determine the physicochemical stability of amiodarone Y-site administered with TPN. Two standard TPN and 2 amiodarone solutions were designed. The 2 TPN differed in the lipid source (Lipofundin MCT/LCT® 20% or SMOFlipid® 20%). The 2 amiodarone solutions were prepared at different concentrations (900 mg and 1200 mg in 250mL of dextrose 5% in water). Each TPN and amiodarone solutions ran at a rate that simulated a 24-hour Y-site infusion to obtain different admixture samples. Each sample was then visually examined and further tested to determine the mean lipid droplet size distribution by dynamic light scattering and amiodarone concentrations by HPLC. No alterations were detected by visual inspection. Average droplet size remained below 500 nm (252.5 ± 5.9 nm for Lipofundin MCT/LCT® TPN and 327.7± 14.4 nm for SMOFlipid® TPN). For the samples obtained after running 900 mg and 1200 mg amiodarone solutions with TPN, the concentrations observed at 24 hours were 0.4491 ± 0.0111 mg/mL and 0.5773 ± 0.0214 mg/mL, respectively. These results represent approximately 100% of the zero-time concentrations and are within ±15% of the predicted values. No degradation products were observed in the chromatograms. Amiodarone is physicochemically compatible with standard TPN via a Y-site administration at the tested amiodarone concentrations.

Total Parenteral Nutrition Standardization and Electronic Ordering to Reduce Errors: a Quality Improvement Initiative.

Total parenteral nutrition (TPN) provides vital intravenous nutrition for patients who cannot tolerate enteral nutrition but is susceptible to medical errors due to its formulation, ordering, and administrative complexities. At Johns Hopkins All Children's Hospital, 22% of TPN orders required clarification of errors and averaged 10 minutes per order for error correction by pharmacists. Quality improvement methodology improved patient safety by standardizing TPN formulations and incorporating TPN ordering processes into the electronic medical record. A multidisciplinary group of providers developed standardized TPN solutions for neonatal and pediatric patients. Inclusion, exclusion, and discontinuation criteria were defined. The primary outcome measure was reducing TPN ordering error rate, and secondary outcomes were improving TPN ordering and processing time along with reducing blood draws. Through multiple plan-do-study-act cycles, we standardized TPN solutions, incorporated them in the electronic medical record, monitored blood draws, and evaluated resource efficiency. Data were analyzed using chi-square tests of independence and t tests for 2 independent samples. The TPN ordering error rate significantly decreased from baseline of 22% to 3.2% over the final quarter of the study period, χ2 (1, N = 2,467) = 89.13, P < 0.001. Order processing time fell from 10 to 5 minutes by project end. The average number of blood draws decreased significantly from 6.2 (SD = 3.12) blood draws to 4.3 (SD = 2.13) in the last quarter of the study, t (506) = 5.97, P < 0.001. Standardizing TPN and transitioning to electronic ordering effectively and significantly reduced ordering errors and processing time. It also substantially improved resource efficiency by reducing the number of blood draws.

Maximization of calcium and phosphate in neonatal total parenteral nutrition.

Appropriate calcium and phosphate supplementation is essential for bone growth in preterm infants. Using Rehabix-K2™ (AY Pharmaceuticals, Tokyo, Japan) and Pleamin-P Injection™ (Fuso Pharmaceutical Industries, Osaka, Japan) as the total parenteral nutrition (TPN) and amino acid solution, respectively, we investigated ways of maximizing calcium and phosphate in the TPN solution. Rehabix-K2, Pleamin-P, calcium gluconate, sodium phosphate, 50% glucose, and water were mixed in varying proportions to create 16 formulations. Precipitation assessment was done three times for each of the 16 formulations, and was based on the Japanese Pharmacopeia. Precipitation was observed 24h after mixing when the calcium and phosphate were 60mEq/L and 30mmol/L or 80mEq/L and 40 mmol/L, respectively. No precipitation was observed when the calcium and phosphate were 20mEq/L and 10mmol/L, respectively. Precipitation was observed once out of three times, when the calcium and phosphate were 40mEq/L and 20mmol/L, respectively, and the amino acids were 2% and 3% (mean pH, 6.13 and 6.26, respectively). No precipitation was observed, however, when the calcium and phosphate were 40mEq/L and 20mmol/L, respectively, and the amino acids were 0% and 1% (mean pH, 5.88 and 6.05, respectively). Not only the concentration of calcium and phosphate, but also the pH of the TPN solution, are crucial factors for precipitation. Based on these results, a well-balanced TPN solution maximizing calcium and phosphate availability will be able to be formulated.

The identification of Meyerozyma guilliermondii from blood cultures and surveillance samples in a university hospital in Northeast Turkey: A ten-year survey

Meyerozyma (Pichia) guilliermondii exists in human skin and mucosal surface microflora. It can cause severe fungal infections like candidemia, which is an opportunistic pathogen. One hundred and forty-one M.guilliermondii isolates, consisting of 122 blood culture isolates, belonging to 126 patients; 13 total parenteral nutrition solution isolates; and two rectal swab isolates were identified according to carbohydrate assimilation reactions in a university hospital in Turkey between January 2006 and December 2015. Following Candida albicans (34.0%) and C.parapsilosis (21.2%), the third yeast species most commonly isolated from blood cultures in the Farabi Hospital was M.guilliermondii (20.6%). The patients were hospitalised in 27 different departments. A total of 50% of the patients were in pediatric departments, 49.2% were in intensive care units, and 17.2% were in haematology-oncology departments. Molecular identification of the isolates was performed using DNA sequence analysis of ribosomal ITS gene regions and IGS amplification-AluI fingerprinting (IGSAF). With molecular identification, 140 isolates were identified as M.guilliermondii and one isolate was identified as Candida membranifaciens. It was observed that the ITS1 region specifically helps in identifying these species. It was demonstrated that biochemical and molecular methods were 99.3% consistent in identifying M.guilliermondii. The Wild-Type (WT) Minimum Inhibitory Concentrations (MICs) distribution of fluconazole, voriconazole, itraconazole, and flucytosine were determined using the Sensititre YeastOne YO2V system after 24h of incubation. One M.guilliermondii strain was determined to be non-WT for fluconazole, voriconazole, itraconazole and flucytosine. In total, three M.guilliermondii strains, for fluconazole, were determined to be non-WT in this study.

Experience of compounding total parenteral nutrition admixtures for preterm infants in a hospital pharmacy: evidence of calcium and phosphate compatibility problem

ObjectiveParenterally fed preterm newborn infants require large amounts of calcium and phosphate in a low volume of solution. The lower the volume of solution, the higher is the possibility of...

Omega-3 fatty acids inhibit oxidative stress in a rat model of liver regeneration.

PurposeLipid peroxidation and consequent reactive oxygen species in the setting of oxidative stress have crucial roles in liver regeneration, which may adversely affect the regeneration itself and lead to liver failure. The aim of the current study is to investigate whether omega-3 fatty acid supplementation inhibits oxidative stress in an experimental model of liver regeneration.MethodsForty rats were allocated to four groups. Rats in group A received a sham operation. Rats in group B were subjected to right portal vein ligation (RPVL) and saline infusion. Rats in groups C and D were subjected to RPVL and total parenteral nutrition (TPN) with an all-in-one admixture containing a soybean oil based lipid emulsion. Rats in group D were additionally supplemented with omega-3 fatty acid infusion. Oxidative stresses in the blood and liver were measured by glutathione, superoxide dismutase, catalase, glutathione peroxidase, malondialdehyde, and nitric oxide.ResultsOmega-3 supplementation to the TPN solution significantly corrected alterations in the blood and tissue concentrations of oxidants and anti-oxidants during regeneration (P < 0.05).ConclusionOmega-3 fatty acid supplementation to the TPN solution revealed promising results in removal of oxidative stress that emerges during liver regeneration.

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

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

Total antioxidant, total oxidant and serum paraoxonase levels according to lipid administration method in parenterally fed premature infants

Objective: The aim of our study was to determine whether lipid solutions delivered separately or in mixture with total parenteral nutrition (TPN) solutions effect the balance between oxidant and antioxidant levels in premature infants.Methods: A total of 60 preterm newborns who were delivered at their 30–34 gestational weeks and received TPN were included in the study. Premature newborns were randomized into two groups based on the delivery method of the lipid solution, separately (Group 1) or in mixture with TPN solutions (Group 2). Total antioxidant status (TAS), total oxidant status (TOS) and paraoxonase (PON-1) levels were analyzed in both blood samples, and oxidative stress index (OSI) was also calculated.Results: Thirty cases from both groups were included in the study. Statistically significant decrease in the level of TAS and increase in the level of PON-1 were detected at 72 h of TPN therapy in both groups (p < 0.05). Statistically significant decrease in both TOS and OSI levels were observed in Group 2 (p < 0.05). In association with these findings, any statistically significant intergroup difference was not detected in both parameters regarding oxidant balance (p > 0.05).Conclusion: Our study showed that according to lipid administration method any difference for oxidant–antioxidant balance was not detected.

Bacterial nutrient foraging in a mouse model of enteral nutrient deprivation: insight into the gut origin of sepsis.

Total parenteral nutrition (TPN) leads to a shift in small intestinal microbiota with a characteristic dominance of Proteobacteria This study examined how metabolomic changes within the small bowel support an altered microbial community in enterally deprived mice. C57BL/6 mice were given TPN or enteral chow. Metabolomic analysis of jejunal contents was performed by liquid chromatography/mass spectrometry (LC/MS). In some experiments, leucine in TPN was partly substituted with [13C]leucine. Additionally, jejunal contents from TPN-dependent and enterally fed mice were gavaged into germ-free mice to reveal whether the TPN phenotype was transferrable. Small bowel contents of TPN mice maintained an amino acid composition similar to that of the TPN solution. Mass spectrometry analysis of small bowel contents of TPN-dependent mice showed increased concentration of 13C compared with fed mice receiving saline enriched with [13C]leucine. [13C]leucine added to the serosal side of Ussing chambers showed rapid permeation across TPN-dependent jejunum, suggesting increased transmucosal passage. Single-cell analysis by fluorescence in situ hybridization (FISH)-NanoSIMS demonstrated uptake of [13C]leucine by TPN-associated bacteria, with preferential uptake by Enterobacteriaceae Gavage of small bowel effluent from TPN mice into germ-free, fed mice resulted in a trend toward the proinflammatory TPN phenotype with loss of epithelial barrier function. TPN dependence leads to increased permeation of TPN-derived nutrients into the small intestinal lumen, where they are predominately utilized by Enterobacteriaceae The altered metabolomic composition of the intestinal lumen during TPN promotes dysbiosis.