Joseph I. Boullata

A Parenteral Nutrition Use Survey With Gap Analysis

BACKGROUNDnParenteral nutrition (PN) is a high-alert medication for which safe practice guidelines are available. Recent adverse events associated with PN have been widely reported. A survey of current practices was indicated as new guidelines are being considered.nnnMETHODSnA web-based survey consisting of 70 items was made available for the month of August 2011. Respondents provided answers to questions that addressed all aspects of the PN use process.nnnRESULTSnThere were a total of 895 respondents to the survey, including dietitians, nurses, pharmacists, and physicians. They predominantly represented hospital settings (89%), with 44% from academic institutions. Most organizations use a once-daily PN admixture with 21% outsourcing preparation. Electronic PN order entry is available in one-third of organizations, and the use of standardized order sets prevails. Unfortunately, electronic interfaces between computer systems remain infrequent, meaning that at least one transcription step is required by most in the PN use process. There are a wide variety of methods for ordering PN components, many of which are inconsistent with safe practices. Most organizations dedicate a pharmacist to review the PN orders, many of which require clarifications. Documentation at each step of the PN use process with oversight to identify deviations from best practice recommendations is infrequent. A significant proportion (44%) does not track PN-related medication errors.nnnCONCLUSIONSnThe survey data are a valuable snapshot of current practices with PN. Poor compliance with some of the safe practice guidelines continues. This will help guide new safety initiatives for the PN use process.

ASPEN Safe Practices for Enteral Nutrition Therapy

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

Standardized Competencies for Parenteral Nutrition Order Review and Parenteral Nutrition Preparation, Including Compounding The ASPEN Model

Parenteral nutrition (PN) is a high-alert medication with a complex drug use process. Key steps in the process include the review of each PN prescription followed by the preparation of the formulation. The preparation step includes compounding the PN or activating a standardized commercially available PN product. The verification and review, as well as preparation of this complex therapy, require competency that may be determined by using a standardized process for pharmacists and for pharmacy technicians involved with PN. An American Society for Parenteral and Enteral Nutrition (ASPEN) standardized model for PN order review and PN preparation competencies is proposed based on a competency framework, the ASPEN-published interdisciplinary core competencies, safe practice recommendations, and clinical guidelines, and is intended for institutions and agencies to use with their staff.

Clinical, Ergonomic, and Economic Outcomes With Multichamber Bags Compared With (Hospital) Pharmacy Compounded Bags and Multibottle Systems A Systematic Literature Review

Background: Multichamber bags (MCBs) may offer potential clinical, ergonomic, and economic advantages compared with (hospital) pharmacy compounded bags (COBs) and multibottle systems (MBSs). Methods: A systematic literature review was performed to identify and assess the available evidence regarding advantages of MCBs compared with COBs and MBSs. Medline, Embase, the Cochrane Databases, and EconLit were searched for articles reporting clinical, ergonomic, and economic outcomes for MCBs compared with COBs or MBSs. The search was limited to studies conducted in hospitalized patients >2 years of age that were published in English between January 1990 and November 2014. The Population Intervention Comparison Outcomes Study Design (PICOS) framework was used for the analysis. Results: From 1307 unique citations, 74 potentially relevant publications were identified; review of references identified 2 additional publications. Among the 76 publications, 18 published studies met the inclusion criteria. Most were retrospective in design. Ten studies reported clinical outcomes, including 1 prospective randomized trial and multiple retrospective analyses that reported a lower risk of bloodstream infection for MCBs compared with other delivery systems. Sixteen studies reported ergonomic and/or economic outcomes; most reported a potential cost benefit for MCBs, with consistent reports of reduced time and labor compared with other systems. The largest cost benefit was observed in studies evaluating total hospitalization costs. Conclusions: The systematic literature review identified evidence of potential clinical, ergonomic, and economic benefits for MCBs compared with COBs and MBSs; however, methodological factors limited evidence quality. More prospective studies are required to corroborate existing evidence.

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.

Nutrition in the Age of Polypharmacy

Preventive medicine includes nutritional approaches for promoting health and for preventing, delaying, or modifying disease processes. Avoiding poor nutritional status is an aspect that has wide ranging benefits on health outcomes. Recognition of risk factors for poor nutritional status is vital to this goal. Alterations to nutritional status may occur for any number of reasons, including the influence of medication. This chapter will provide a review on the potential changes in nutritional status resulting from medication use.

Reduction of Parenteral Nutrition and Hydration Support and Safety With Long-Term Teduglutide Treatment in Patients With Short Bowel Syndrome−Associated Intestinal Failure: STEPS-3 Study

BACKGROUNDnPatients with intestinal failure associated with short bowel syndrome (SBS-IF) require parenteral support (PS) to maintain fluid balance or nutrition. Teduglutide (TED) reduced PS requirements in patients with SBS-IF in the randomized, placebo (PBO)-controlled STEPS study (NCT00798967) and its 2-year, open-label extension, STEPS-2 (NCT00930644).nnnMETHODSnSTEPS-3 (NCT01560403), a 1-year, open-label extension study in patients with SBS-IF who completed STEPS-2, further monitored the safety and efficacy of TED (0.05xa0mg/kg/day). Baseline was the start of TED treatment, in either STEPS or STEPS-2. At the end of STEPS-3, patients treated with TED in both STEPS and STEPS-2 (TED-TED) received TED forxa0≤42xa0months, and patients treated with TED only in STEPS-2 (no TED treatment [NT]/PBO-TED) received TED forxa0≤36 months.nnnRESULTSnFourteen patients enrolled (TED-TED, nxa0=xa05; NT/PBO-TED, nxa0=xa09) and 13 completed STEPS-3. At the last dosing visit, mean (SD) PS was reduced from baseline by 9.8 (14.4 [50%]) and 3.9 (2.8 [48%]) L/week in TED-TED and NT/PBO-TED, respectively. Mean (SD) PS infusions decreased by 3.0 (4.6) and 2.1 (2.2) days per week from baseline in TED-TED and NT/PBO-TED, respectively. Two patients achieved PS independence; 2 additional patients who achieved independence in STEPS-2 maintained enteral autonomy throughout STEPS-3. All patients reportedxa0≥1 treatment-emergent adverse event (TEAE); 3 patients had TEAEs that were reported as treatment related. No patient had a treatment-related treatment-emergent serious AE.nnnCONCLUSIONSnLong-term TED treatment yielded a safety profile consistent with previous studies, sustained efficacy, and a further decline in PS requirements.

A rational approach to vitamin D supplementation.

Most U.S. adults have vitamin D insufficiency [1]. Similar data are available from large cohorts in other nations [2–4]. Given the limited food sources and sun avoidance, oral vitamin D supplementation is often used to correct deficits and prevent associated conditions. The pharmacologic disposition and clinical effect of vitamin D supplementation have been reviewed in depth [5]. Active vitamin D metabolites play autocrine and paracrine roles in addition to the well-described endocrine function; this has increased calls for individuals to maintain an adequate vitamin D status. The influence of vitamin D on disease prevention or progression is based on the vitamin D status documented in epidemiologic and intervention studies. The serum 25-hydroxyvitamin D (25[OH]D) concentration is the accepted indicator of vitamin D status. It serves as a substrate for the active metabolites produced by many tissues. This biomarker reflects exposure todand subsequent hydroxylation ofdvitamin D from endogenous synthesis, food, and supplement intake. A vitamin D status assessment helps identify those requiring supplementation. The Institute of Medicine (IOM) has recommended 50 nmol/L as the 25(OH)D cutoff value indicative of vitamin D sufficiency, with concentrations below 30 nmol/L defining a risk of deficiency [6]. The IOM notwithstanding, a more broadly accepted cutoff for vitamin D sufficiency, proposed by the Endocrine Society (ES), is a 25(OH)D concentration of 75 nmol/L based on skeletal outcome [7].

Standardized Competencies for Parenteral Nutrition Administration: The ASPEN Model

Parenteral nutrition (PN) is a highly complex medication and its provision can be prone to a variety of errors. Safe administration of this therapy requires that the competency of clinicians, particularly nurses, be demonstrated using a standardized process. In this document, a standardized model for PN administration competency is proposed based on a competency framework, the ASPEN-published interdisciplinary core competencies, discipline-specific standards of practice, safe practice recommendations, and clinical guidelines. ASPEN recognizes that all healthcare institutions may not currently meet the aspirational goals of this document. This framework will guide institutions and agencies in developing tools and procedures and maintaining competency of staff members around safe PN administration. The ASPEN Board of Directors has approved this document.

Nutritional Assessment in Obese Patients

As the prevalence of obesity has risen, clinicians must evaluate nutritional status across a range of patient obesity levels and in varied clinical settings. Assessment of the nutritional status of obese patients may be challenging but follows the same schema as for undernourished patients. Patients who undergo bariatric surgery are cared for by multiple nutrition professionals at varied times relative to surgery. The early nutritional assessment evaluates the suitability for surgery and needed lifestyle modifications including dietary, nutritional supplement, and physical activity behaviors. If patients have a surgical complication, they may require a short course of parenteral nutrition that will require assessment of nutrient intake requirements. If patients fail to thrive, most typically at later times after malabsorptive surgical procedures, assessment for micronutrient deficiencies may also be indicated.