Carol J. Rollins

Systematic review of clinical adverse events reported after acute intravenous lipid emulsion administration

Abstract Background: Intravenous lipid emulsions (ILEs) were initially developed to provide parenteral nutrition. In recent years, ILE has emerged as a treatment for poisoning by local anesthetics and various other drugs. The dosing regimen for the clinical toxicology indications differs significantly from those used for parenteral nutrition. The evidence on the efficacy of ILE to reverse acute toxicity of diverse substances consists mainly of case reports and animal experiments. Adverse events to ILE are important to consider when clinicians need to make a risk/benefit analysis for this therapy. Methods: Multiple publication databases were searched to identify reports of adverse effects associated with acute ILE administration for either treatment of acute poisoning or parenteral nutrition. Articles were selected based on pre-defined criteria to reflect acute use of ILE. Experimental studies and reports of adverse effects as a complication of long-term therapy exceeding 14 days were excluded. Results: The search identified 789 full-text articles, of which 114 met the study criteria. 27 were animal studies, and 87 were human studies. The adverse effects associated with acute ILE administration included acute kidney injury, cardiac arrest, ventilation perfusion mismatch, acute lung injury, venous thromboembolism, hypersensitivity, fat embolism, fat overload syndrome, pancreatitis, extracorporeal circulation machine circuit obstruction, allergic reaction, and increased susceptibility to infection. Conclusion: The emerging use of ILE administration in clinical toxicology warrants careful attention to its potential adverse effects. The dosing regimen and context of administration leading to the adverse events documented in this review are not generalizable to all clinical toxicology scenarios. Adverse effects seem to be proportional to the rate of infusion as well as total dose received. Further safety studies in humans and reporting of adverse events associated with ILE administration at the doses advocated in current clinical toxicology literature are needed.

Methodology for AACT evidence-based recommendations on the use of intravenous lipid emulsion therapy in poisoning

Abstract Intravenous lipid emulsion (ILE) therapy is a novel treatment that was discovered in the last decade. Despite unclear understanding of its mechanisms of action, numerous and diverse publications attested to its clinical use. However, current evidence supporting its use is unclear and recommendations are inconsistent. To assist clinicians in decision-making, the American Academy of Clinical Toxicology created a workgroup composed of international experts from various clinical specialties, which includes representatives of major clinical toxicology associations. Rigorous methodology using the Appraisal of Guidelines for Research and Evaluation or AGREE II instrument was developed to provide a framework for the systematic reviews for this project and to formulate evidence-based recommendations on the use of ILE in poisoning. Systematic reviews on the efficacy of ILE in local anesthetic toxicity and non-local anesthetic poisonings as well as adverse effects of ILE are planned. A comprehensive review of lipid analytical interferences and a survey of ILE costs will be developed. The evidence will be appraised using the GRADE system. A thorough and transparent process for consensus statements will be performed to provide recommendations, using a modified Delphi method with two rounds of voting. This process will allow for the production of useful practice recommendations for this therapy.

Low Itraconazole Serum Concentrations Following Administration of Itraconazole Suspension to Critically Ill Allogeneic Bone Marrow Transplant Recipients

Objective: To report itraconazole serum concentrations following administration of itraconazole suspension via orogastric feeding tubes to 2 critically ill allogeneic bone marrow transplant recipients. Case Summaries: A 38-year-old man and a 29-year-old man, each allogeneic bone marrow transplant recipients, were treated with oral itraconazole for documented fungal infections. Intubation and mechanical ventilation impeded ingestion of itraconazole capsules. Itraconazole was prepared initially as a suspension in intravenous lipid emulsion 20% and later as a suspension in citric acid 1.5% in D5W USP. Itraconazole serum concentrations were assayed using HPLC. Predose itraconazole serum concentrations were undetectable to 72 ng/mL. Postdose itraconazole serum concentrations were 5–97 ng/mL. Itraconazole concentrations measured in these patients were markedly lower than serum concentrations reported in the literature for similar doses administered to fed subjects. Discussion: Efficacy of this antifungal agent is limited currently by the patients ability to ingest and absorb the itraconazole capsules. Pathophysiologic factors and suspension formulation issues that likely contributed to decreased itraconazole absorption are discussed. Conclusions: Preparation and administration of itraconazole as a suspension did not enhance drug absorption in these patients. Furthermore, efficacy of itraconazole suspension may be affected by physical compatibility and chemical stability of the extemporaneous preparations.

Three-in-One Parenteral Nutrition: A Safe and Economical Method of Nutritional Support for Infants

The medical records of 20 infants under 1 year of age who received parenteral nutrition (PN) for a minimum of 1 week were reviewed. Patients were divided into two groups based on the method of PN administration. One group received PN by the traditional two-plus-one method where lipid emulsion is given separately from the dextrose-amino acid mixture. The second group received PN by the three-in-one method where lipid emulsion is admixed with the dextrose and amino acids. There were no statistically significant differences between the two groups in the amount of calories, lipid, dextrose, protein, calcium, and phosphorus received per kg of body weight. Average daily weight gain was not statistically different, and no obvious trends were noted in serum biochemical parameters between the two groups. Average total PN days for the groups (13 +/- 7 days for the two-plus-one group vs 39 +/- 35 days for the three-in-one group) were significantly different (p less than 0.05). A cost comparison of the two methods of PN administration indicated that the two-plus-one method costs our hospital

Significant Publications for Pharmacy Nutrition Support Practice in 2013

11.78 more per day than the three-in-one solution. We conclude that the three-in-one method of PN administration is safe, efficacious, and cost effective for infants under 1 year of age.

Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 18th Edition

Purpose To assist the pharmacy clinician engaged in nutrition support in staying current with the most pertinent literature. Methods Several experienced board-certified clinical pharmacists in nutrition support compiled a list of publications published in 2013 that they considered to be important to their practice. The citation list was compiled into a Web-based survey whereby pharmacist members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), GI-Liver-Nutrition Practice Research Network of the American College of Clinical Pharmacy, and the Pharmacy and Pharmacology Section of the Society of Critical Care Medicine were asked to rank each article according to level of importance in their practice. Results A total of 30 articles were identified by the author group. Thirty-six participants responded to the survey. The top-ranked papers by participants from the Web-based survey were reviewed by the authors. Due to its high level of importance, the parenteral nutrition safety consensus recommendations article, to be published in 2014 by A.S.P.E.N., was also reviewed. Conclusion It is recommended that the informed pharmacist, who is engaged in nutrition support therapy, be familiar with the majority of these publications.

Drug-nutrient interactions in patients receiving enteral nutrition.

Self-Care Components of Selected Chronic Disorders (Chapter 45). Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care (17th Edition). Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care up-to-date product availability information, whereas the 17th edition includes some. Pharmacists, firth edition, Robert McCarthy, Jones and Handbook of Nonprescription Drugs: an Interactive. Approach to SelfCare. 17th ed. Washington, DC:.

Effects of Intravenous Lipid Emulsions in Postoperative Patients

Malnourished patients and those at risk of malnutrition are candidates for nutrition intervention. This includes previously well-nourished patients who have been or will be without oral intake for 3 to 5 d (pediatric populations) or 5 to 10 d (adults). Enteral nutrition (EN), which is synonymous with tube feeding, should be considered when a patient cannot, will not, or should not consume appropriate quantities of nutrients by mouth to prevent malnutrition. There are few absolute contraindications to tube feeding other than a bowel obstruction that cannot be bypassed. However, conditions such as diffuse peritonitis, intractable vomiting, intractable diarrhea, and ischemia of the small bowel may be contraindications to EN therapy (1). Most other conditions allow at least some nutrients to be delivered enterally.

Allergic and pseudoallergicreactions

The essential nature of intravenous lipid emulsion (ILE) in preventing essential fatty acid deficiency in patients requiring parenteral nutrition (PN) is undisputed, and its role in providing a balanced caloric source is well recognized. These seemingly simple roles, however, mask the complex and competitive nature of fatty acid biochemistry. Different fat sources provide different fatty acid profiles and have the potential for distinct effects, both beneficial and adverse, throughout the body. Adverse effects attributed to the traditional soybean oil and soybean-safflower oil ILEs include hepatic, pulmonary, and immune system dysfunction. This has resulted in continued investigation into other fat sources

Omega-3 fatty acids and the increased risk of bleeding

Abstract Allergic reactions, or hypersensitivity reactions, can be associatedwith any class of drug and with any type of pharmaceuticalproduct, including OTCs. They can develop at any age and can be outgrown.Many allergic reactions are mild and easily treated with OTCantihistamines; others result in significant cant morbidity, and a few resultin mortality. Anaphylactic shock and asphyxiation from throat swellingare the two most common causes of death from anaphylactic reactions,which result in about 500 deaths per year in the United States. 1