-
Nutrients Mar 2020The right amount and quality of amino acids (AAs) supplied to patients on parenteral nutrition (PN) reduces muscle mass loss, may preserve or even increase it, with... (Review)
Review
The right amount and quality of amino acids (AAs) supplied to patients on parenteral nutrition (PN) reduces muscle mass loss, may preserve or even increase it, with significant clinical benefits. Several industrial PN mixtures are available so that nutrition specialists can choose the product closest to the patient's needs. In selected cases, there is the possibility of personalizing compounded mixtures in a hospital pharmacy that completely meets the individual nutritional needs of PN patients. This narrative review deals with the AA solutions used in PN mixtures. The physiology, the methods to calculate the AA needs, and the AA and energy requirements suggested by scientific guidelines for each patient type are also reported.
Topics: Amino Acids; Humans; Nutrients; Nutritional Requirements; Parenteral Nutrition Solutions; Parenteral Nutrition, Total
PubMed: 32183395
DOI: 10.3390/nu12030772 -
American Journal of Health-system... Jun 2024This article is based on presentations and discussions held at the International Safety and Quality of Parenteral Nutrition (PN) Summit concerning the acute care...
PURPOSE
This article is based on presentations and discussions held at the International Safety and Quality of Parenteral Nutrition (PN) Summit concerning the acute care setting. Some European practices presented in this article do not conform with USP general chapter <797> requirements. Nevertheless, the purpose is to cover the challenges experienced in delivering high-quality PN within hospitals in the United States and Europe, in order to share best practices and experiences more widely.
SUMMARY
Core issues regarding the PN process within an acute care setting are largely the same everywhere: There are ongoing pressures for greater efficiency, optimization, and also concurrent commitments to make PN safer for patients. Within Europe, in recent years, the use of market-authorized multi-chamber bags (MCBs) has increased greatly, mainly for safety, cost-effectiveness, and efficiency purposes. However, in the US, hospitals with low PN volumes may face particular challenges, as automated compounding equipment is often unaffordable in this setting and the variety of available MCBs is limited. This can result in the need to operate several PN systems in parallel, adding to the complexity of the PN use process. Ongoing PN quality and safety initiatives from US institutions with various PN volumes are presented. In the future, the availability of a greater selection of MCBs in the US may increase, leading to a reduction in dependence on compounded PN, as has been seen in many European countries.
CONCLUSION
The examples presented may encourage improvements in the safety and quality of PN within the acute care setting worldwide.
Topics: Humans; Europe; Hospitals; Parenteral Nutrition; Parenteral Nutrition Solutions; Patient Safety; Pharmacy Service, Hospital; United States; Congresses as Topic
PubMed: 38869256
DOI: 10.1093/ajhp/zxae080 -
American Journal of Health-system... Jun 2024Parenteral nutrition (PN) is an established therapy when oral/enteral feeding is not sufficient or is contraindicated, but nevertheless PN remains a complex, high-alert... (Review)
Review
PURPOSE
Parenteral nutrition (PN) is an established therapy when oral/enteral feeding is not sufficient or is contraindicated, but nevertheless PN remains a complex, high-alert medication that is susceptible to errors that may affect patient safety. Over time, considerable progress has been made to make PN practices safer. The purpose of this article is to address ongoing challenges to improve the PN use process from prescription to administration and monitoring, and to outline practical aspects fostering the safety, quality, and cost-effectiveness of PN, as discussed at the International Safety and Quality of PN Summit.
SUMMARY
Opportunities to improve the PN use process in clinical practice include the promotion of inter-disciplinary communication, vigilant surveillance for complications, staff education to increase competency, and more consistent use of advanced technologies that allow automated safety checks throughout the PN process. Topics covered include considerations on PN formulations, including the value of intravenous lipid emulsions (ILEs), trends in compounding PN, the current and future role of market-authorized multi-chamber PN bags containing all 3 macronutrients (amino acids, glucose/dextrose, and ILE) in the United States and in Europe, and strategies to cope with the increasing global problem of PN product shortages.
CONCLUSION
This review outlines potential strategies to use in clinical practice to overcome ongoing challenges throughout the PN use process, and ultimately promote PN patient safety.
Topics: Humans; Parenteral Nutrition; Patient Safety; Fat Emulsions, Intravenous; United States; Internationality; Europe
PubMed: 38869257
DOI: 10.1093/ajhp/zxae079 -
American Journal of Health-system... Jun 2024This article is based on presentations and discussions held at the International Safety and Quality of Parenteral Nutrition (PN) Summit (held November 8-10, 2021, at...
PURPOSE
This article is based on presentations and discussions held at the International Safety and Quality of Parenteral Nutrition (PN) Summit (held November 8-10, 2021, at Charleston, SC, and Bad Homburg, Germany) and aims to raise awareness concerning unresolved issues associated with the PN process and potential future directions, including a greater emphasis on patients' perspectives and the role of patient support.
SUMMARY
Ensuring that every patient in need receives adequate PN support remains challenging. It is important to have a standardized approach to identify nutritional risk and requirements using validated nutritional screening and assessment tools. Gaps between optimal and actual clinical practices need to be identified and closed, and responsibilities in the nutrition support team clarified. Use of modern technology opens up opportunities to decrease workloads or liberate resources, allowing a more personalized care approach. Patient-centered care has gained in importance and is an emerging topic within clinical nutrition, in part because patients often have different priorities and concerns than healthcare professionals. Regular assessment of health-related quality of life, functional outcomes, and/or overall patient well-being should all be performed for PN patients. This will generate patient-centric data, which should be integrated into care plans. Finally, communication and patient education are prerequisites for patients' commitment to health and for fostering adherence to PN regimes.
CONCLUSION
Moving closer to optimal nutritional care requires input from healthcare professionals and patients. Patient-centered care and greater emphasis on patient perspectives and priorities within clinical nutrition are essential to help further improve clinical nutrition.
Topics: Humans; Parenteral Nutrition; Patient Safety; Patient-Centered Care; Quality Improvement; Quality of Life; Congresses as Topic
PubMed: 38869258
DOI: 10.1093/ajhp/zxae077 -
Seminars in Fetal & Neonatal Medicine Jun 2022Nutritional support is a fundamental component of the care of the extremely preterm infant, including the "micro preemie" (here defined as a baby born weighing less than... (Review)
Review
Nutritional support is a fundamental component of the care of the extremely preterm infant, including the "micro preemie" (here defined as a baby born weighing less than 500 g), but goes beyond considerations of milk as a food. This is because milk from an infant's own mother, unlike currently available substitutes, additionally provides invaluable non-nutritive benefits. Nutritional support requires suitable devices or techniques to administer nutrients enterally or intravenously, products shown to be safe in preterm populations, and efficacy demonstrated in respect of important functional outcomes. Sadly, preterm feeding remains characterised by a deficit of evidence. In this chapter, we will briefly describe the history of preterm nutrition, discuss current enteral and parenteral practice, important evidence gaps, a summary of approaches for evaluating nutritional practice, and key considerations for future endeavour. Our discussion refers to all extremely preterm infants and it not confined to the micro preemie.
Topics: Enteral Nutrition; Humans; Infant; Infant Formula; Infant Nutritional Physiological Phenomena; Infant, Newborn; Infant, Premature; Milk, Human; Nutritional Status; Parenteral Nutrition
PubMed: 35718688
DOI: 10.1016/j.siny.2022.101344 -
Critical Care (London, England) 2015This review emphasizes the benefits of parenteral nutrition (PN) in critically ill patients, when prescribed for relevant indications, in adequate quantities, and in due... (Review)
Review
This review emphasizes the benefits of parenteral nutrition (PN) in critically ill patients, when prescribed for relevant indications, in adequate quantities, and in due time. Critically ill patients are at risk of energy deficit during their ICU stay, a condition which leads to unfavorable outcomes, due to hypercatabolism secondary to the stress response and the difficulty to optimize feeding. Indirect calorimetry is recommended to define the energy target, since no single predictive equation accurately estimates energy expenditure. Energy metabolism is intimately associated with protein metabolism. Recent evidence calls for adequate protein provision, but there is no accurate method to estimate the protein requirements, and recommendations are probably suboptimal. Enteral nutrition (EN) is the preferred route of feeding, but gastrointestinal intolerance limits its efficacy and PN allows for full coverage of energy needs. Seven recent articles concerning PN for critically ill patients were identified and carefully reviewed for the clinical and scientific relevance of their conclusions. One article addressed the unfavorable effects of early PN, although this result should be more correctly regarded as a consequence of glucose load and hypercaloric feeding. The six other articles were either in favor of PN or concluded that there was no difference in the outcome compared with EN. Hypercaloric feeding was not observed in these studies. Hypocaloric feeding led to unfavorable outcomes. This further demonstrates the beneficial effects of an early and adequate feeding with full EN, or in case of failure of EN with exclusive or supplemental PN. EN is the first choice for critically ill patients, but difficulties providing optimal nutrition through exclusive EN are frequently encountered. In cases of insufficient EN, individualized supplemental PN should be administered to reduce the infection rate and the duration of mechanical ventilation. PN is a safe therapeutic option as long as sufficient attention is given to avoid hypercaloric feeding.
Topics: Critical Care; Critical Illness; Energy Intake; Energy Metabolism; Enteral Nutrition; Evidence-Based Medicine; Female; Humans; Male; Parenteral Nutrition; Treatment Outcome
PubMed: 26728859
DOI: 10.1186/cc14723 -
ESMO Open Jun 2020Clinical guidelines recommend that parenteral nutrition (PN) is added to enteral nutrition (EN; supplemental parenteral nutrition (SPN)) in order to meet energy and... (Review)
Review
BACKGROUND
Clinical guidelines recommend that parenteral nutrition (PN) is added to enteral nutrition (EN; supplemental parenteral nutrition (SPN)) in order to meet energy and protein needs in patients with cancer when EN alone is insufficient. However, although cancer-related malnutrition is common, there is poor awareness of the value of nutritional care, resulting in SPN being chronically underused.
METHODS
We performed a targeted literature review and exploratory cost-utility analysis to gather evidence on the clinical effectiveness of SPN, and to estimate the potential cost-effectiveness of SPN versus EN alone in an example cancer setting.
RESULTS
The literature review identified studies linking SPN with malnutrition markers, and studies linking malnutrition markers with clinical outcomes. SPN was linked to improvements in body mass index (BMI), fat-free mass, phase angle (PhA) and prealbumin. Of these markers, BMI and PhA were strong predictors of survival. By combining published data, we generated indirect estimates of the overall survival HR associated with SPN; these ranged from 0.80 to 0.99 (mode 0.87). In patients with Stage IV inoperable pancreatic cancer, the incremental cost-effectiveness ratio versus EN alone was estimated to be £41 350 or £91 501 depending on whether nursing and home delivery costs for EN and SPN were combined or provided separately.
CONCLUSION
Despite a lack of direct evidence, the results of the literature review demonstrate that SPN may provide important clinical and quality of life benefits to patients with cancer. The potential for any improvement in outcomes in the modelled patient population is very limited, so cost-effectiveness may be greater in patients with less severe disease and other types of cancer.
Topics: Cost-Benefit Analysis; Critical Illness; Enteral Nutrition; Humans; Parenteral Nutrition; Quality of Life
PubMed: 32576610
DOI: 10.1136/esmoopen-2020-000709 -
Advances in Nutrition (Bethesda, Md.) Mar 2022
Topics: Humans; Copper; Parenteral Nutrition; Parenteral Nutrition, Total; Nutritional Status
PubMed: 34940824
DOI: 10.1093/advances/nmab157 -
Nutricion Hospitalaria Aug 2023This ESPEN practical guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providers in a concise way...
This ESPEN practical guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providers in a concise way about the indications and contraindications for HEN, as well as its implementation and monitoring. This guideline will also inform interested patients requiring HEN. Home parenteral nutrition is not included but will be addressed in a separate ESPEN guideline. The guideline is based on the ESPEN scientific guideline published before, which consists of 61 recommendations that have been reproduced and renumbered, along with the associated commentaries that have been shorted compared to the scientific guideline. Evidence grades and consensus levels are indicated. The guideline was commissioned and financially supported by ESPEN and the members of the guideline group were selected by ESPEN.
Topics: Humans; Enteral Nutrition; Societies, Scientific; Parenteral Nutrition, Home; Consensus
PubMed: 37409729
DOI: 10.20960/nh.04796 -
Cleveland Clinic Journal of Medicine Nov 2016Intestinal failure is a serious complication of conditions such as inflammatory bowel disease, mesenteric ischemia, and radiation enteritis--and of extensive bowel... (Review)
Review
Intestinal failure is a serious complication of conditions such as inflammatory bowel disease, mesenteric ischemia, and radiation enteritis--and of extensive bowel resection performed because of these diseases. Imbalances of fluids and electrolytes and poor nutritional status manifest as chronic diarrhea or increased ostomy output. Prompt referral to a center specializing in intestinal rehabilitation is key to achieving nutritional homeostasis and, in some cases, can help the patient return to oral food intake. We review the intestinal sequelae of bowel resection and provide an update on intestinal rehabilitation with dietary modification, drug therapy, and parenteral nutrition. We also review current experience with intestinal transplant, a potentially lifesaving option in select patients when intestinal rehabilitation fails or parenteral nutrition causes severe complications.
Topics: Diet Therapy; Digestive System Surgical Procedures; Gastrointestinal Agents; Humans; Intestinal Diseases; Organ Dysfunction Scores; Parenteral Nutrition; Recovery of Function; Water-Electrolyte Imbalance
PubMed: 27824535
DOI: 10.3949/ccjm.83a.15045