David S. Seres

A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations

Parenteral nutrition (PN) serves as an important therapeutic modality that is used in adults, children, and infants for a variety of indications. The appropriate use of this complex therapy aims to maximize clinical benefit while minimizing the potential risks for adverse events. Complications can occur as a result of the therapy and as the result of the PN process. These consensus recommendations are based on practices that are generally accepted to minimize errors with PN therapy, categorized in the areas of PN prescribing, order review and verification, compounding, and administration. These recommendations should be used in conjunction with other A.S.P.E.N. publications, and researchers should consider studying the questions brought forth in this document.

Advantages of enteral nutrition over parenteral nutrition

It is a strong and commonly held belief among nutrition clinicians that enteral nutrition is preferable to parenteral nutrition. We provide a narrative review of more recent studies and technical reviews comparing enteral nutrition with parenteral nutrition. Despite significant weaknesses in the existing data, current literature continues to support the use of enteral nutrition in patients requiring nutrition support, over parenteral nutrition.

Standardized Competencies for Parenteral Nutrition Prescribing The American Society for Parenteral and Enteral Nutrition Model

Parenteral nutrition (PN) provision is complex, as it is a high-alert medication and prone to a variety of potential errors. With changes in clinical practice models and recent federal rulings, the number of PN prescribers may be increasing. Safe prescribing of this therapy requires that competency for prescribers from all disciplines be demonstrated using a standardized process. A standardized model for PN prescribing competency is proposed based on a competency framework, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)-published interdisciplinary core competencies, safe practice recommendations, and clinical guidelines. This framework will guide institutions and agencies in developing and maintaining competency for safe PN prescription by their staff.

2005 American society for parenteral and enteral nutrition (A.S.P.E.N.) standards and guidelines survey

An online survey about the use and format of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Standards and Guidelines documents was conducted. The survey was sent to A.S.P.E.N. members, and an acceptable number of responses were received (470, or 9% of those surveyed). Most respondents indicated an overall satisfaction with the standards and guidelines and suggested format changes, many of which will be incorporated into future guidelines and standards. The results of this survey are presented here for general interest. Changes in the process with which A.S.P.E.N. produces standards and guidelines are discussed.

Safety of Enteral Feeding in Patients With Open Abdomen, Upper Gastrointestinal Bleed, and Perforation Peritonitis

Provision of enteral nutrition (EN) has historically been withheld after major abdominal operations until bowel activity returns. Evidence suggests that EN is safe in critically ill patients with a variety of illnesses, specifically after abdominal surgery. There is a strong association between poor nutrition status and worse outcomes in critically ill patients. The fear has been that EN, by virtue of increased luminal pressure or demand to the splanchnic circulation, may compromise the integrity of anastomotic repairs and place patients at risk for complications. In this review, the authors analyze the safety of EN in the setting of the open abdomen, upper gastrointestinal bleeding, and perforation peritonitis, with evidence from published clinical trials and meta-analyses.

A Prospective Randomized Trial of the Effects of Early Enteral Feeding After Radical Cystectomy

OBJECTIVE To investigate the role of early feeding on recovery after radical cystectomy and urinary diversion. Enhanced recovery protocols have helped to standardize postoperative recovery. This is the first study to directly review the impact of early feeding on recovery in a randomized multi-institutional protocol. METHODS From 2011 to 2014, patients at 2 large hospitals were randomized after radical cystectomy to receive access to liquids and then a regular diet on postoperative days 1 and 2 or conventional care with introduction of a liquid diet after return of bowel activity, typically days 3-5. Early ambulation, use of metoclopramide, and no nasogastric tube were standard for all patients. The study was powered to detect a 50% decrease in 90-day complication rate with secondary end points of length of stay, time to bowel activity, and time to diet tolerance. The study was terminated early due to slow accrual (102 of 328). RESULTS Overall complications for the early vs standard groups were similar (34 vs 31, P = .86). Immediate inpatient and postdischarge complication rates were also similar (P = .63 and P = .44). Length of stay was not different (8.74 days vs 9.69 days, P = .43). Rates of ileus (27% vs 41%, P = .21) and return of bowel function (4.67 days vs 4.09 days, P = .62) were the same in arms. CONCLUSION Although this prospective randomized study did not meet the accrual target, early introduction of diet was well tolerated and did not show a negative or positive difference in any outcomes. Enhanced recovery protocols standardize postoperative care and early feeding is a well-tolerated addition.

Utility of Electronic Medical Records to Assess the Relationship Between Parenteral Nutrition and Central Line–Associated Bloodstream Infections in Adult Hospitalized Patients

BACKGROUND Parenteral nutrition is associated with increased central line-associated bloodstream infections (CLABSIs). Electronic databases are important for identifying independent risk factors for prevention strategies. Our aims were to evaluate the utility of using electronic data sources to identify risk factors for CLABSIs, including parenteral nutrition (PN), and to assess the association between CLABSI and PN administration. METHODS Data were obtained for all discharges of adult patients in whom a central line was inserted between September 1, 2007, and December 31, 2008, in a large, academically affiliated hospital in New York City. CLABSI was defined electronically using a modified definition from the Centers for Disease Control and Prevention. A manual chart review was also undertaken to assess validity/reliability of the electronic database and gather additional information. Risk factors for CLABSI were examined using logistic regression. RESULTS Among 4840 patients, there were 220 CLABSIs, an incidence of 5.4 CLABSIs per 1000 central line days. Risk factors included PN (odds ratio [OR], 4.33; 95% confidence interval [CI], 2.50-7.48), intensive care unit stay (OR, 2.26; 95% CI, 1.58-3.23), renal disease (OR, 2.79; 95% CI, 2.00-3.88), and immunodeficiency (OR, 2.26; 95% CI, 1.70-3.00). Diabetes mellitus was associated with reduced CLABSI rates (OR, 0.63; 95% CI, 0.45-0.88). CONCLUSIONS The utility of electronic medical records for determining risk factors is limited by such things as free-text data entry. Using a hybrid between fully electronic and manual chart review, reliable data were obtained. PN is associated with a high risk for CLABSI in a population highly selected for indications for PN.

Supplementation of l-Alanyl-l-Glutamine and Fish Oil Improves Body Composition and Quality of Life in Patients With Chronic Heart Failure

Background—Skeletal muscle dysfunction and exercise intolerance are clinical hallmarks of patients with heart failure. These have been linked to a progressive catabolic state, skeletal muscle inflammation, and impaired oxidative metabolism. Previous studies suggest beneficial effects of &ohgr;-3 polyunsaturated fatty acids and glutamine on exercise performance and muscle protein balance. Methods and Results—In a randomized double-blind, placebo-controlled trial, 31 patients with heart failure were randomized to either L-alanyl-L-glutamine (8 g/d) and polyunsaturated fatty acid (6.5 g/d) or placebo (safflower oil and milk powder) for 3 months. Cardiopulmonary exercise testing, dual-energy x-ray absorptiometry, 6-minute walk test, hand grip strength, functional muscle testing, echocardiography, and quality of life and lateral quadriceps muscle biopsy were performed at baseline and at follow-up. Oxidative capacity and metabolic gene expression were analyzed on muscle biopsies. No differences in muscle function, echocardiography, 6-minute walk test, or hand grip strength and a nonsignificant increase in peak VO2 in the treatment group were found. Lean body mass increased and quality of life improved in the active treatment group. Molecular analysis revealed no differences in muscle fiber composition, fiber cross-sectional area, gene expression of metabolic marker genes (PGC1&agr;, CPT1, PDK4, and GLUT4), and skeletal muscle oxidative capacity. Conclusions—The combined supplementation of L-alanyl-L-glutamine and polyunsaturated fatty acid did not improve exercise performance or muscle function but increased lean body mass and quality of life in patients with chronic stable heart failure. These findings suggest potentially beneficial effects of high-dose nutritional polyunsaturated fatty acids and amino acid supplementations in patients with chronic stable heart failure. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01534663.

Lipid Injectable Emulsion Survey with Gap Analysis

Background: Lipid injectable emulsion (ILE) is an integral part of parenteral nutrition (PN), providing energy and essential fatty acids. With recent consensus recommendations for PN, clinical guidelines for ordering and preparation of PN, the U.S. Food and Drug Administration approval of new ILE products, and revised ILE labeling to include a 1.2-micron filter, a gap in current practice knowledge was apparent. Materials and Methods: The American Society for Parenteral and Enteral Nutrition PN Safety Committee surveyed clinicians on how ILE products are prescribed, prepared, and administered to patients from neonates to adults. Results: The results of this survey conducted in late 2016 found a wide variation in practice, particularly across patient age groups. Conclusion: These findings demonstrate the need for ongoing dissemination and education on standardized safe practices for ILE use.

Zinc Deficiency With Dermatitis in a Parenteral Nutrition–Dependent Patient Due to National Shortage of Trace Minerals

The shortages of intravenous drugs remains critical, with sterile injectables accounting for 80% of the approximately 300 shortages. The impact is being felt in patients dependent on parenteral nutrition (PN), and severe deficiencies are becoming more commonplace. We report here a man who developed severe zinc deficiency, manifesting as a painful desquamative rash, due to an inability to obtain multi-trace element additives for his PN.