Vincent W. Vanek

A.S.P.E.N. Position Paper: Recommendations for Changes in Commercially Available Parenteral Multivitamin and Multi–Trace Element Products

The parenteral multivitamin preparations that are commercially available in the United States (U.S.) meet the requirements for most patients who receive parenteral nutrition (PN). However, a separate parenteral vitamin D preparation (cholecalciferol or ergocalciferol) should be made available for treatment of patients with vitamin D deficiency unresponsive to oral vitamin D supplementation. Carnitine is commercially available and should be routinely added to neonatal PN formulations. Choline should also be routinely added to adult and pediatric PN formulations; however, a commercially available parenteral product needs to be developed. The parenteral multi-trace element (TE) preparations that are commercially available in the U.S. require significant modifications. Single-entity trace element products can be used to meet individual patient needs when the multiple-element products are inappropriate (see Summary/A.S.P.E.N. Recommendations section for details of these proposed modifications).

A.S.P.E.N. Position Paper Clinical Role for Alternative Intravenous Fat Emulsions

The currently available, standard soybean oil (SO)-based intravenous fat emulsions (IVFEs) meet the needs of most parenteral nutrition (PN) patients. There are alternative oil-based fat emulsions, such as medium-chain triglycerides (MCTs), olive oils (OOs), and fish oils (FOs), that, based on extensive usage in Europe, have an equivalent safety profile to SO. These alternative IVFEs are metabolized via different pathways, which may lead to less proinflammatory effects and less immune suppression. These alternative oil-based IVFEs are not currently available in the United States. Many patients who require IVFEs are already in a compromised state. Such patients could potentially have better clinical outcomes when receiving one of the alternative IVFEs to diminish the intake of the potentially proinflammatory ω-6 fatty acid-linoleic acid-which comprises more than 50% of the fatty acid profile in SO. Further research is needed on these alternative oil-based IVFEs to identify which IVFE oils or which combination of oils may be most clinically useful for specific patient populations.

A.S.P.E.N. Position Paper Parenteral Nutrition Glutamine Supplementation

The parenteral multivitamin preparations that are commercially available in the United States (U.S.) meet the requirements for most patients who receive parenteral nutrition (PN). However, a separate parenteral vitamin D preparation (cholecalciferol or ergocalciferol) should be made available for treatment of patients with vitamin D deficiency unresponsive to oral vitamin D supplementation. Carnitine is commercially available and should be routinely added to neonatal PN formulations. Choline should also be routinely added to adult and pediatric PN formulations; however, a commercially available parenteral product needs to be developed. The parenteral multi–trace element (TE) preparations that are commercially available in the U.S. require significant modifications. Single-entity trace element products can be used to meet individual patient needs when the multiple-element products are inappropriate (see Summary/A.S.P.E.N. Recommendations section for details of these proposed modifications).

Ins and Outs of Enteral Access: Part 2—Long Term Access—Esophagostomy and Gastrostomy

Access techniques for long-term enteral nutrition (over 4 to 6 weeks) includes cervical esophagostomy and pharyngostomy, gastrostomy, and jejunostomy. Cervical esophagostomy and pharyngostomy are rarely used since the advent of better long-term enteral access techniques that are easier to care for and have fewer complications; they are briefly reviewed only for historical completeness and to condemn their use. The different techniques of gastrostomy tube insertion and their indications, contraindications, advantages, and disadvantages are discussed. Part III (to be published in a later issue) of this series will review feeding jejunostomy.

The ins and outs of venous access: Part I

Selection of the proper venous access device is important to maximize patient benefit and minimize patient discomfort, morbidity, mortality, and cost. The decision of which device to use is based on whether or not the patient requires central venous access and whether the need is short-term (<6 to 8 weeks) or long-term. Short-term venous access devices include short peripheral IV catheters, midline catheters, peripherally inserted central catheters (PICC), and central venous catheters (CVC). This article reviews each of these short-term devices and their indications, contraindications, advantages, and disadvantages. Part 1 covers Venous Anatomy and Short-Term Venous Access; Part 2, to be published in the June issue, covers Long-Term Venous Access.

Ins and outs of enteral access. Part 1: short-term enteral access.

Proper selection of the type of enteral access in a given clinical situation is important to maximize the benefit to the patient and minimize the discomfort to the patient, the morbidity and mortality, and the cost. This decision is based on whether or not the patient needs short-term (<4-6 weeks) or long-term enteral nutrition support. This article focuses on short-term access including nasogastric (NG) and nasoenteric (NE) tubes and reviews each of these enteral access tubes along with their indications, contraindications, advantages, and disadvantages.

Ins and Outs of Enteral Access. Part 3: Long-Term Access—Jejunostomy

Feeding jejunostomy tubes can be useful in patients with gastroesophageal reflux or a nonfunctioning stomach and can be short-term, long-term, or permanent. These tubes can be inserted surgically, endoscopically, radiologically, or laparoscopically. Each of these techniques is described, and their mortality, morbidity, advantages, and disadvantages are compared.

A Call to Action to Bring Safer Parenteral Micronutrient Products to the U.S. Market

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) started an intensive review of commercially available parenteral vitamin and trace element (TE) products in 2009. The chief findings were that adult multi-TE products currently available in the United States (U.S.) provide potentially toxic amounts of manganese, copper, and chromium, and neonatal/pediatric multi-TE products provide potentially toxic amounts of manganese and chromium. The multivitamin products appeared safe and effective; however, a separate parenteral vitamin D product is needed for those patients on standard therapy who continue to be vitamin D depleted and are unresponsive to oral supplements. The review process also extended to parenteral choline and carnitine. Although choline and carnitine are not technically vitamins or trace elements, choline is an essential nutrient in all age groups, and carnitine is an essential nutrient in infants, according to the Food and Nutrition Board of the Institute of Medicine. A parenteral choline product needs to be developed and available. Efforts are currently under way to engage the U.S. Food and Drug Administration (FDA) and the parenteral nutrient industry so A.S.P.E.N.s recommendations can become a commercial reality.

Follow-Up Survey on Functionality of Nutrition Documentation and Ordering Nutrition Therapy in Currently Available Electronic Health Record Systems

BACKGROUND This is a follow-up survey to reassess the safety and efficacy of nutrition content in the available electronic health record (EHR) systems. MATERIALS AND METHODS Members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), American Society for Nutrition, and the Academy for Nutrition and Dietetics were asked to participate in an online survey. The survey included questions from a 2012 EHR survey on the safety and efficacy in 5 nutrition content areas as well as questions from previous 2003 and 2011 A.S.P.E.N. parenteral nutrition (PN) surveys. RESULTS Percent of respondents using an EHR and using the EHR for less than 1 year increased between 2012 and 2014 (86%-94%, P < .05; 11%-16%, P < .05, respectively). However, there was no improvement in the safety and efficacy of the 5 nutrition content areas, with a significant decrease in 2 of these areas, ordering oral nutrition supplements and ordering PN. The top-rated EHR vendors had a higher average favorable response rate in regards to safety and efficacy in the nutrition content areas but even the top-rated EHR vendor had only a 60% average in favorable responses. Reported use of electronic PN ordering and a direct interface between the EHR and the automated compounding device (ACD) significantly increased from 2003 to 2011 to 2014 (29% to 33% to 63% and 16% to 19% to 28%, respectively, P < .05). CONCLUSIONS This is a call to action to nutrition support clinicians, societies, and organizations to proactively be involved in initiatives to educate clinicians and collaborate with EHR vendors to enhance the EHR systems to improve the safety and efficacy of providing nutrition therapy in hospitalized patients.

Closed versus Open Enteral Delivery Systems: A Quality Improvement Study

The purpose of this study was to review the compliance rate with maximum enteral feeding hang-time policy and to determine the incidence of tube feeding (TF) contamination. This study found the compliance rate for the maximum TF bag hang-time was 67% for open delivery system (OS) and 88% for the closed delivery system (CS). The 10 CS bags cultured had hang-times from 20.8 to 45.8 hours and were all sterile. The 8 OS bags cultured had hang-times from 6.8 to 26.6 hours with 2 bags being contaminated. The maximum hang-time for the CS was increased from 24 to 48 hours. The study was repeated with 100% compliance for the CS and still only 50% compliance for the OS. The 14 CS bags cultured had hang-times from 22.0 to 47.3 hours and were all sterile except for 1 bag that had methylene blue dye added to it. The 9 OS bags cultured had hang-times from 7.5 to 13.3 hours, and all were sterile. The findings of this study led us to conclude that closed enteral delivery systems should be used whenever possible.